Risk Factors of Mortality After Liver Transplantation in Uruguay

INTRODUCTION

Identification of predictive factors of mortality in a liver transplant (LT) program optimizes patient selection and allocation of organs.

OBJECTIVE

To determine survival rates and predictive factors of mortality after LT in the National Liver Transplant Program of Uruguay.

METHODS

A retrospective study was conducted analyzing data prospectively collected into a multidisciplinary database. All patients transplanted since the beginning of the program on July 2009 to April 2017 were included (n = 148). Twenty-nine factors were analyzed through the univariate Kaplan-Meier model. A Cox regression model was used in the multivariate analysis to identify the independent prognostic factors for survival.

RESULTS

Overall survival was 92%, 87%, and 78% at discharge, 1 year, and 3 years, respectively. The Kaplan-Meier survival curves were significantly lower in: recipients aged >60 years, Model for End-Stage Liver Disease score >21, LT due to hepatocellular carcinoma (HCC) and acute liver failure (ALF), donors with comorbidities, intraoperative blood loss beyond the median (>2350 mL), red blood cell transfusion requirement beyond the median (>1254 mL), intraoperative complications, delay of extubation, invasive bacterial, and fungal infection after LT and stay in critical care unit >4 days. The Cox regression model (likelihood ratio test, P = 1.976 e^-06) identified the following independent prognostic factors for survival: LT for HCC (hazard ratio [HR] 4.511; P = .001) and ALF (HR 6.346; P = .004), donors with comorbidities (HR 2.354; P = .041), intraoperative complications (HR 2.707; P = .027), and invasive fungal infections (HR 3.281; P = .025).

CONCLUSION

The survival rates of LT patients as well as the mortality-associated factors are similar to those reported in the international literature.

Ultrasound-guided internal jugular vein catheterization: a randomized controlled trial

INTRODUCTION

Even though advantages of ultrasound line placement seem obvious, many countries do not have easy access to such technology. This study aims to compare the degree of difficulty in central venous line placement with or without ultrasound and the incidence of complications, and to establish the effect of the operator's degree of training.

METHODS

The study included 257 patients that required central venous catheterization during the study period. Patients were divided into groups according to the operator's experience: expert group (over 70 central accesses performed before the study) (n=152) and in-training or non-expert group. Procedures were randomized to "without ultrasound" (n=80 expert and 54 non-expert) and "with ultrasound" (n=72 expert and 51 non-expert).

RESULTS

Catheter placements were more successful in the "expert" and in the "with ultrasound" than in the "non-expert" (88% vs 79%; p=0.04) or in the "without ultrasound" groups (91% vs 78%; p=0.005). Incidence of complications was 11.7%, with no significant difference among "with ultrasound" (8.1%) and "without ultrasound" (14.9%) groups. However, the "non-expert" group had fewer complications with the use of ultrasound (7.8% vs 24%).

CONCLUSIONS

Ultrasound reduces the incidence of complications when placement is performed by inexperienced operators. Centers with residents should emphasize the necessity of ultrasound for central line catheterization. Training in ultrasound might be of paramount importance in the effectiveness of the technique.

Intraoperative hyponatremia during craniofacial surgery

BACKGROUND

Hyponatremia is an important cause of morbidity in some groups of hospitalized children. Our aim is to describe the incidence and severity of intraoperative hyponatremia in children undergoing craniofacial surgery, and determine the associated risk factors.

METHODS

A descriptive retrospective study of children who underwent primary craniofacial surgery between March 1994 and February 2008 was performed. All administered fluids contained a minimum sodium concentration of 140 mmol.l(-1). Hyponatremia was classified as follows: severe < or =125 mmol.l(-1); moderate 126-130 mmol.l(-1); and, mild 131-134 mmol.l(-1).

RESULTS

Hundred and seven cases are reported. Severe, moderate and mild intraoperative hyponatremia occurred in 14 (13%), 21 (19%) and 23 (22%) children respectively. Mannitol was given to 31 (29%) children, but was not associated with the development of hyponatremia. Neither the type nor duration of surgery, type of fluid replacement nor hourly urinary output, was associated with development of hyponatremia. Most episodes of significant intraoperative hyponatremia (44%) were detected between the 2nd and the 4th hour of surgery. There were no identified neurological sequelae (e.g. coma, neurological deficit) attributable to the hyponatremia.

CONCLUSION

Despite strict avoidance of low sodium solutions (<140 mmol.l(-1)), hyponatremia occurs frequently in children undergoing craniofacial surgery in our practice; and is unrelated to the administration of mannitol. Although the mechanisms are yet to be determined, anesthesiologists should be aware of this issue and be prepared to monitor and treat this potentially serious complication.