Resource implications of expanding the use of donation after circulatory determination of death in liver transplantation.

In the United Kingdom, liver transplantation using donation after circulatory determination of death (DCDD) organs has increased steadily over the last few years and now accounts for 20% of UK transplant activity. The procurement of DCDD livers is actively promoted as a means of increasing the donor pool and bridging the evolving disparity between the wait-list length and the number of transplants performed. The objective of this retrospective study of a cohort of patients who were matched for age, liver disease etiology, and Model for End-Stage Liver Disease score was to determine whether differences in perioperative costs and resource utilization are associated with the use of such organs. Our results showed an increased prevalence of reperfusion syndrome in the DCDD cohort (P < 0.001), a prolonged heparin effect (P = 0.01), a greater incidence of hyperfibrinolysis (P = 0.002), longer periods of postoperative ventilator use (P = 0.03) and vasopressor support (P = 0.002), and a prolonged length of stay in the intensive therapy unit (ITU; P = 0.02). The peak posttransplant aspartate aminotransferase level was higher in the DCDD group (P = 0.007), and there was significantly more graft failure at 12 months (P = 0.03). In conclusion, we have demonstrated different perioperative and early postoperative courses for DCDD and donation after brain death (DBD) liver transplants. The overall quality of DCDD grafts is poorer; as a result, the length of the ITU stay and the need for multiorgan support are increased, and this has significant financial and resource implications. We believe that these implications require a careful real-life consideration of benefits. It is essential for DCDD not to be seen as a like-for-like alternative to DBD and for every effort to be continued to be made to increase the number of donations from brain-dead patients as a first resort.

Red blood cell storage is associated with length of stay and renal complications after cardiac surgery.

BACKGROUND: The association of red blood cell (RBC) storage on morbidity outcome after cardiac surgery is debated. We sought to clarify the association of the age of transfused blood on outcome in patients undergoing cardiac surgery. STUDY DESIGN AND METHODS: Data were drawn from a prospective, observational cohort study of morbidity outcome in patients undergoing cardiac surgery. Blood transfusion data were obtained retrospectively via the Trust blood bank electronic records. Old blood was defined as more than 14 days old. The primary outcome measure was postoperative length of stay (PLOS). Secondary outcome measures included renal failure and morbidity as defined within the postoperative morbidity survey. RESULTS: A total of 176 (39.6%) of 444 participants received a blood transfusion. Patients transfused with new blood had a reduced PLOS compared with patients receiving exclusively old or any old blood (old blood ± new blood; 7 days vs. 8 days, p = 0.04 and vs. 10 days, p = 0.002, respectively). In patients who only had 1 unit transfused, PLOS was longer in those receiving only old blood compared with those receiving only new blood (8 days vs. 6 days, p = 0.02) with a 3.8-fold risk of longer stay. Compared with patients receiving exclusively new blood, patients receiving any old blood had a higher incidence of new renal complications (65.7% vs. 43.9%, p = 0.008). Each 1-day increase in storage was associated with a 7% increase in risk of new renal complications. CONCLUSION: Our data support previous suggestions of an association between transfusion of older RBCs and poorer outcome in cardiac surgery patients. Randomized controlled trials are required to determine the true causal nature of any such association.

Neuromodulation of innate immunity by remote ischaemic conditioning in humans: Experimental cross-over study.

Experimental animal studies on the mechanisms of remote ischaemic conditioning (RIC)-induced cardioprotection against ischaemia/reperfusion injury demonstrate involvement of both neuronal and humoral pathways. Autonomic parasympathetic (vagal) pathways confer organ protection through both direct innervation and/or immunomodulation, but evidence in humans is lacking. During acute inflammation, vagal release of acetylcholine suppresses CD11b expression, a critical ß2-integrin regulating neutrophil adhesion to the endothelium and transmigration to sites of injury. Here, we tested the hypothesis that RIC recruits vagal activity in humans and has an anti-inflammatory effect by reducing neutrophil CD11b expression. Participants (age:50 â€‹± â€‹19 years; 53% female) underwent ultrasound-guided injection of local anaesthetic within the brachial plexus before applying 3 â€‹× â€‹8 min cycles of brachial artery occlusion using a blood pressure cuff (RICblock). RIC was repeated 6 weeks later without brachial plexus block. Masked analysers quantified vagal activity (heart rate, heart rate variability (HRV)) before, and 10 â€‹min after, the last cycle of RIC. RR-interval increased after RIC (reduced heart rate) by 40 â€‹ms (95% confidence intervals (95%CI):13-66; n â€‹= â€‹17 subjects; P â€‹= â€‹0.003). RR-interval did not change after brachial plexus blockade (mean difference: 20 â€‹ms (95%CI:-11 to 50); P â€‹= â€‹0.19). The high-frequency component of HRV was reduced after RICblock, but remained unchanged after RIC (P â€‹< â€‹0.001), indicating that RIC preserved vagal activity. LPS-induced CD16+CD11b+ expression in whole blood (measured by flow cytometry) was reduced by RIC (3615 median fluorescence units (95%CI:475-6754); P = 0.026), compared with 2331 units (95%CI:-3921 to 8582); P = 0.726) after RICblock. These data suggest that in humans RIC recruits vagal cardiac and anti-inflammatory mechanisms via ischaemia/reperfusion-induced activation of sensory nerve fibres that innervate the organ undergoing RIC.

Opioids Cause Central and Complex Sleep Apnea in Humans and Reversal With Discontinuation: A Plea for Detoxification.

ABSTRACT: Central sleep apnea (CSA) and continuous positive airway pressure (CPAP) emergent CSA are common in patients for whom opioids have been prescribed for chronic pain management. It is not known if opioids are the potential cause of CSA. We report the case of a patient who underwent multiple full nights of polysomnography testing while on opioids, off opioids, and with various positive airway pressure devices. While on opioids, the patient had severe CSA that persisted during both CPAP and bilevel titration but was eliminated with adaptive servoventilation therapy. Some time later, opioid use was discontinued by the patient. Repeat polysomnography showed resolution of the sleep-disordered breathing. Later-while the patient was still off opioids-she had gained weight and become symptomatic; polysomnography showed obstructive sleep apnea without CSA. This time, therapy with CPAP showed elimination of sleep apnea without emergent CSA. These data collectively indicate that opioids were the cause of CSA as well as emergent CSA.

Beneficial effect of intra-operative methylprednisolone on immediate post liver transplant intensive care course.

BACKGROUND: Concern about the effect of corticosteroids on outcomes following liver transplantation (LT), especially in recipients with hepatitis C infection (HCV) has lead many centres to abandon the use of perioperative steroids. Avoidance of corticosteroids in immunosuppressive regimens may have beneficial effects in terms of reducing the incidence of infection, new onset diabetes mellitus and HCV recurrence however perioperative use may have beneficial effects such as attenuation of ischaemia-reperfusion injury (IR) and treatment of underlying adrenal insufficiency (AI). Due to a high prevalence of adrenal insufficiency in patients on our waiting list for LT, we reintroduced the use of intraoperative methyl-prednisolone and hypothesised that this would improve early post operative outcome. MATERIAL AND METHODS: 90 consecutive patients were studied, 45 before (group 1) and 45 (group 2) after the protocolised reintroduction of methylprednisolone (1g IV) intraoperatively prior to reperfusion. Peri- and post-transplant requirements for colloid, crystalloid, blood products, vasopressors, renal replacement therapy and ventilation were compared between groups. No other changes to the transplant protocol occurred during the study period. RESULTS: Patients who received intraoperative methlyprednisolone had significantly shorter post operative ITU stay, vasopressor and colloid requirement post LT, and were dependent on mechanical ventilation for less time. CONCLUSIONS: These data suggest that the use of intraoperative methylprednisolone can modify the immediate post transplant course of LT, either by attenuating reperfusion induced inflammation, or by addressing hitherto unrecognized adrenal insufficiency.

Survey of international regional anesthesia fellowship directors.

BACKGROUND: The scope of regional anesthesia fellowship programs has not been analyzed but may provide insights that could improve fellowship training and standards. METHODS: Regional anesthesia fellowship directors across the world were asked to complete a comprehensive survey that detailed the range of educational and practical experience and attitudes as well as assessment procedures offered in their programs. RESULTS: The survey response rate was 66% (45/68). Overall, the range of activities and the time and resources committed to education during fellowships is encouraging. A wide range of nerve block experience is reported with most programs also offering acute pain management, research, and teaching opportunities. Only two-thirds of fellowships provide formal feedback. This feedback is typically a formative assessment. CONCLUSION: This is the first survey of regional anesthesia fellowship directors, and it illustrates the international scope and continuing expansion of education and training in the field. The results should be of interest to program directors seeking to benchmark and improve their educational programs and to faculty involved in further curriculum development.

Restless legs syndrome and periodic limb movements of sleep: fact, fad, and fiction.

Restless legs syndrome (RLS) and periodic limb movements of sleep (PLMS) are common disorders seen in sleep disorder centers. Although RLS in universally thought to cause daytime sleepiness, the role of PLMS in causing sleepiness (or any symptom!) has been more controversial. Recent publications have show that PLMS do not cause either subjective or objective sleepiness, but may be a marker for respiratory effort related arousals. In regards to patients with end-stage renal disease, PLMS may mark mortality. In this same group of patients, gabapentin and normalization of hematocrit may be effective therapies for RLS/PLMS. Melatonin may prove to be an alternative therapy for PLMS.

The Dretler stone cone: a device to prevent ureteral stone migration-the initial clinical experience.

PURPOSE: Retrograde stone migration during ureteroscopic lithotripsy occurs in 5% to 40% of proximal and distal ureteral stone cases. This migration increases morbidity and the need for auxiliary procedures. The Dretler stone cone (Medsource, Norwell, Massachusetts) is a novel device to prevent proximal stone migration and facilitate fragment extraction during ureteroscopic lithotripsy. We assessed the safety and efficacy of the Dretler stone cone in the clinical setting and compared it prospectively with a conventional flat wire basket during ureteroscopy for ureteral calculi. MATERIALS AND METHODS: To our knowledge we report the initial clinical use of the Dretler stone cone in 50 consecutive patients with ureteral calculi undergoing ureteroscopic extraction. Calculi were situated above the sacroiliac joint in 24 cases, over the sacroiliac joint in 15 and below the sacroiliac joint in 11. Pneumatic lithotripsy was done in 42 cases. In the remaining 8 cases ureteroscopic (3) or fluoroscopic (5) intact stone extraction was performed. The later 23 cases using the Dretler stone cone were prospectively compared with 20 of ureteroscopic intracorporeal lithotripsy using a standard flat wire basket. RESULTS: The Dretler stone cone was successfully placed in all 50 cases. In 41 patients it was placed via cystoscopy under fluoroscopic guidance, while 9 impacted stones required ureteroscopic placement. Six patients in whom the Dretler stone cone was used had residual fragments less than 3 mm. No patient required auxiliary procedures. In the prospective trial no patients in Dretler stone cone group had residual fragments greater than 3 mm. or required auxiliary procedures. However, in the flat wire basket group residual stones greater than 3 mm. were present in 6 cases (30%, p <0.001), while auxiliary procedures were required in 4 (20%, p <0.01). CONCLUSIONS: The Dretler stone cone represents a new generation of basketry that minimizes proximal ureteral stone migration and allows safe extraction of fragments during ureteroscopic lithotripsy. In our experience it is associated with a lower incidence of significant residual fragments and fewer auxiliary procedures than conventional flat wire baskets.