Randomized Controlled Trial of Enhanced Recovery After Surgery Protocols in Live Kidney Donors: ERASKT Study.

Background: Enhanced recovery after surgery (ERAS) pathways represent a comprehensive approach to optimizing perioperative management and reducing hospital stay and cost. In living donor kidney transplantation, key impediments to postoperative discharge include pain, and opioid associated complications such as nausea, vomiting, and the return of gastrointestinal function. Methods: In this randomized controlled trial, living kidney transplantation donors were assigned to either the ERAS or control group. The ERAS group patients received 15 preoperative, 17 intraoperative, 19 postoperative element intervention. The control group received standard care. The ERAS group received a multimodal opioid sparing pain management including an intraoperative transverse abdominis plane block. Our primary outcome measure was postoperative opioid consumption. The secondary outcome measures were postoperative pain scores, first oral intake, and hospital length of stay. Results: There were no significant differences in demographics between the 2 groups. The ERAS group had a statistically significant reduction in total postoperative opioid consumption calculated in intravenous morphine equivalents (24.2 ±â€…20.2 versus 71 ±â€…39.5 mg, P < 0.01). Postoperative pain scores were significantly lower (P < 0.001) from 1 h postoperatively to 48 h. Surgical time was 45 min shorter (P = 0.037). Intraoperative PlasmaLyte administration was lower (PlasmaLyte: 1444 ±â€…907 versus 2168 ±â€…1347 mL, P = 0.049). Time to tolerating regular diet was shorter by 2 h (P < 0.008), and length of hospital stay was decreased by 10.1 h. Conclusions: The ERAS group experienced superior postoperative analgesia and a shorter length of hospital stay compared with controls.

Viscoelastic testing guided coagulation management in factor VII deficiency for spinal anaesthesia and caesarean section.

The risks and benefits of spinal anaesthesia must be assessed in patients with coagulation disorders. A woman in her 20s with congenital factor VII (FVII) deficiency (31%) was admitted at 38 weeks for caesarean delivery. A rotational thromboelastometry (ROTEM) analysis showed normal coagulation and spinal anaesthesia was performed safely. A repeated ROTEM analysis after haemostasis and uterine closure showed normal coagulation without fibrinolysis. No prophylactic FVII was administered, resulting in a cost savings of US$12 884. FVII level did not predict bleeding or fibrinolysis and FVII and tranexamic acid were not indicated.

Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room.

BACKGROUND: Little is known about reintubations outside of the operating room. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside operating room (OR), including intensive care unit (ICU) and nonICU settings. METHODS: A retrospective cohort study. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were location and indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital-stay, 30-day in-hospital mortality, and overall in-hospital mortality. RESULTS: A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. (41%) of the reintubations occurred in a non-ICU setting. Reintubations occurred after up to 30-days after extubation. Most frequently between 7 and 30 days (32.8%, n = 20). Most of the reintubated patients were reintubated just once (56.9%; n = 29), but some were reintubated 2 times (29.4%; n = 15) or over 3 times (13.7%; n = 7). Reintubated patients had significant longer total ICU-stay (24 ± 3 days vs 12 ± 1 day, p < .001), hospital stay (37 ± 3 vs18 ± 1, p < .001), and total intubation days (8 ± 1 vs 7 ± 0.6, P < .02). The 30-day in-hospital mortality in reintubated patients was 13.7% (n = 7) compared to nonreintubated patients 35.9% (n = 80; P = .002). CONCLUSION: Reintubation was associated with a significant increase in hospital and ICU stay. The higher mortality rate among nonreintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation.

Proceedings of the 28th Annual Congress of the International Liver Transplantation Society.

The 2023 Joint International Congress of the International Liver Transplantation Society (ILTS), the European Liver and Intestine Transplant Association (ELITA), and the Liver Intensive Care Group of Europe (LICAGE) held in Rotterdam, the Netherlands, marked a significant recovery milestone for the liver transplant community after COVID-19. With 1159 participants and a surge in abstract submissions, the event focused on "Liver Disorders and Transplantation: Innovations and Evolving Indications." This conference report provides a comprehensive overview of the key themes discussed during the event, encompassing Hepatology, Anesthesia and Critical Care, Acute Liver Failure, Infectious Disease, Immunosuppression, Pediatric Liver Transplantation, Living Donor Liver Transplantation, Transplant Oncology, Surgical Approaches, and Machine Perfusion. The congress provided a platform for extensive discussions on a wide range of topics, reflecting the continuous advancements and collaborative efforts within the liver transplant community.

Anesthesia and Critical Care for the Prediction and Prevention for Small-for-size Syndrome: Guidelines from the ILTS-iLDLT-LTSI Consensus Conference.

BACKGROUND: During the perioperative period of living donor liver transplantation, anesthesiologists and intensivists may encounter patients in receipt of small grafts that puts them at risk of developing small for size syndrome (SFSS). METHODS: A scientific committee (106 members from 21 countries) performed an extensive literature review on aspects of SFSS with proposed recommendations. Recommendations underwent a blinded review by an independent expert panel and discussion/voting on the recommendations occurred at a consensus conference organized by the International Liver Transplantation Society, International Living Donor Liver Transplantation Group, and Liver Transplantation Society of India. RESULTS: It was determined that centers with experience in living donor liver transplantation should utilize potential small for size grafts. Higher risk recipients with sarcopenia, cardiopulmonary, and renal dysfunction should receive small for size grafts with caution. In the intraoperative phase, a restrictive fluid strategy should be considered along with routine use of cardiac output monitoring, as well as use of pharmacologic portal flow modulation when appropriate. Postoperatively, these patients can be considered for enhanced recovery and should receive proactive monitoring for SFSS, nutrition optimization, infection prevention, and consideration for early renal replacement therapy for avoidance of graft congestion. CONCLUSIONS: Our recommendations provide a framework for the optimal anesthetic and critical care management in the perioperative period for patients with grafts that put them at risk of developing SFSS. There is a significant limitation in the level of evidence for most recommendations. This statement aims to provide guidance for future research in the perioperative management of SFSS.

Proceedings of the 27th Annual Congress of the International Liver Transplantation Society.

After a virtual congress in 2021 and a previous absence in 2020 because of the coronavirus disease 2019 pandemic, the 27th Annual Congress of the International Liver Transplantation Society was held from May 4 to 7, 2022, in a hybrid format in Istanbul, with 1123 (58% on-site) liver transplant professionals from 61 countries attending the meeting. The hybrid format successfully achieved a balance of much yearned-for "in-person interaction" and global online participation. Almost 500 scientific abstracts were presented. In this report, the Vanguard Committee aims to present a summary of key invited lectures and selected abstracts for the liver transplant community.

Native Whole Blood (TRUE-NATEM) and Recalcified Citrated Blood (NATEM) Reference Value Validation with ROTEM Delta.

Background: Thromboelastography is a viscoelastic test of whole blood hemostasis. Currently, no reference value exists for native whole blood and recalcified citrated blood without activators. The aim of this study was to compare the results of ROTEM® tests using fresh native blood without decalcification "TRUE-NATEM" with those using decalcified citrated blood "NATEM" and provide reference values for each. Methods: Inclusion criteria were healthy adult volunteers (18-65 years). Exclusion criteria were any medical condition or medication affecting coagulation. Native whole blood testing was defined as "TRUE-NATEM-test." For recalcified citrated blood testing, the NATEM function was used on ROTEM®. Result: The reference value for TRUE-NATEM was CT: 872-1595s, A10: 14-34 mm, A20: 26-48 mm, CFT: 314-839s, MCF: 34-55 mm, and alpha angle: 17-40°. The reference value for NATEM was CT: 757-1327s, A10: 19-43 mm, A20: 33-55 mm, CFT: 219-615s, MCF: 37-61 mm, alpha angle: 24-51°, and ML: 0-3%. When comparing the reference value of NATEM to TRUE-NATEM, the CT and CFT values are decreased and the MCF and alpha angle are increased. The recalcification process of citrated blood in NATEM shows significant activation of coagulation. Female healthy volunteers had enhanced coagulation when activators were used. Age-related statistical difference was seen when activators were used. Ethnicity did not show any difference on the ROTEM values. Conclusion: We determined the reference value for native whole blood and recalcified whole blood using ROTEM®. A significant discrepancy in native whole blood and recalcified citrated blood coagulation was found. Our study underlines the importance of native whole blood as the gold standard reference value in coagulation.

A 36-Year-Old Woman with Acute Liver Failure Following Acetaminophen Overdose, Raised INR of 8.7, and Normal Blood Viscosity Measured by Rotational Thromboelastometry (ROTEM).

BACKGROUND Fulminant hepatic failure (FHF) is commonly associated with elevated prothrombin time (PT) and international normalized ratio (INR). There is a commensurate decline in pro- and anti-hemostatic factors, and hemostatic function is rebalanced, not reflected in INR. This report presents the case of a 36-year-old woman with FHF following acetaminophen overdose, an increased INR above 8.7, and normal blood viscosity measured by rotational thromboelastometry (ROTEM). CASE REPORT A 36-year-old woman presented with FHF following an acetaminophen overdose. On arrival, she was lethargic but arousable and followed commands. Her King's College Criteria for acetaminophen toxicity was 2 and her MELD score was 36. Her INR was unmeasurably high (>8.7). To evaluate whole-blood coagulation, a ROTEM analysis was performed. All parameters (CT, CFT, alpha-angle, A10, MCF) of the NATEM were within reference range. Despite the normal ROTEM, spontaneous bleeding was a concern. The patient received 5 units of cryoprecipitate and 9 units of FFP prior to a central venous line placement. She was started on molecular adsorbent recirculating system and continuous veno-venous hemodialysis, but died on day 7. CONCLUSIONS Patients with FHF can have normal whole-blood coagulation based on ROTEM even if INR levels are unmeasurably high. Viscoelastic tests such as ROTEM, which assesses whole-blood coagulation properties, are preferrable for coagulation monitoring in these patients. Blood product transfusion to correct coagulation abnormality, like FFP and cryoprecipitate, may be used based on the result of viscoelastic testing over conventional coagulation testing.

Proceedings of the 26th Annual Virtual Congress of the International Liver Transplantation Society.

After a 1-y absence due to the coronavirus disease 2019 pandemic, the 26th Annual Congress of the International Liver Transplantation Society was held from May 15 to 18, 2021, in a virtual format. Clinicians and researchers from all over the world came together to share their knowledge on all the aspects of liver transplantation (LT). Apart from a focus on LT in times of coronavirus disease 2019, featured topics of this year's conference included infectious diseases in LT, living donation, machine perfusion, oncology, predictive scoring systems and updates in anesthesia/critical care, immunology, radiology, pathology, and pediatrics. This report presents highlights from invited lectures and a review of the select abstracts. The aim of this report, generated by the Vanguard Committee of International Liver Transplantation Society, is to provide a summary of the most recent developments in clinical practice and research in LT.

Intraoperative transfusion management, antifibrinolytic therapy, coagulation monitoring and the impact on short-term outcomes after liver transplantation-A systematic review of the literature and expert panel recommendations.

BACKGROUND: Liver transplantation (LT) is frequently complicated by coagulopathy associated with end-stage liver disease (ESLD), that is, often multifactorial. OBJECTIVES: The objective of this systematic review was to identify evidence based intraoperative transfusion and coagulation management strategies that improve immediate and short-term outcomes after LT. METHODS: PRISMA-guidelines and GRADE-approach were followed. Three subquestions were formulated. (Q); Q1: transfusion management; Q2: antifibrinolytic therapy; and Q3: coagulation monitoring. RESULTS: Sixteen studies were included for Q1, six for Q2, and 10 for Q3. Q1: PRBC and platelet transfusions were associated with higher mortality. The use of prothrombin complex concentrate (PCC) and fibrinogen concentrate (FC) were not associated with reductions in intraoperative transfusion or increased thrombotic events. The use of cell salvage was not associated with hepatocellular carcinoma (HCC) recurrence or mortality. Cell salvage and transfusion education significantly decreased blood product transfusions. Q2: Epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA) were not associated with decreased blood product transfusion, improvements in patient or graft survival, or increases in thrombotic events. Q3: Viscoelastic testing (VET) was associated with decreased allogeneic blood product transfusion compared to conventional coagulation tests (CCT) and is likely to be cost-effective. Coagulation management guided by VET may be associated with increases in FC and PCC use. CONCLUSION: Q1: A specific blood product transfusion practice is not recommended (QOE; low | Recommendation; weak). Cell salvage and educational interventions are recommended (QOE: low | Grade of Recommendation: moderate). Q2: The routine use of antifibrinolytics is not recommended (QOE; low | Recommendation; weak). Q3: The use of VET is recommended (QOE; low-moderate | Recommendation; strong).

Preoperative Evaluation and Anesthetic Management of Patients With Liver Cirrhosis Undergoing Cardiac Surgery.

Preoperative evaluation and anesthetic management of patients with liver cirrhosis undergoing cardiac surgery remain a clinical challenge because of its high risk for perioperative complications. This narrative review article summarizes the pathophysiology and anesthetic implication of liver cirrhosis on each organ system. It will help physicians to evaluate surgical candidates, to optimize intraoperative management, and to anticipate complications in liver cirrhosis patients undergoing cardiac surgery. Morbidity typically results from bleeding, sepsis, multisystem organ failure, or hepatic insufficiency. These complications occur as a result of the presence of coagulopathy, poor nutritional status, immune dysfunction, cirrhotic cardiomyopathy, and renal and pulmonary dysfunction that occur with liver cirrhosis. Therefore, liver cirrhosis should not be seen as a single disease, but one that manifests with multiorgan dysfunction. Cardiac surgery in patients with liver cirrhosis increases the risk of perioperative complications, and it presents a particular challenge to the anesthesiologist in that nearly every aspect of normally functioning physiology may be jeopardized in a unique way. Accurately classifying the extent of liver disease, preoperative optimization, and surgical risk communication with the patient are crucial. In addition, all teams involved in the surgery should communicate openly and coordinate in order to ensure optimal care. To reduce perioperative complications, consider using off-pump cardiopulmonary bypass techniques and optimal perfusion modalities to mimic current physiologic conditions.

Severe Congenital Factor VII Deficiency with Normal Perioperative Coagulation Profile Based on ROTEM Analysis in a Hepatectomy.

BACKGROUND Factor VII (FVII) deficiency is the most common autosomal-recessive bleeding disorder. FVII activity level (FVII: C) of 10-20% is often used as the threshold for administering activated recombinant FVII (rFVIIa) for patients undergoing major surgery. However, rFVIIa is expensive and carries the risk of a thromboembolic event, and thus should only be administered when truly indicated. CASE REPORT A 22-year-old woman with 8% FVII: C underwent a hepatectomy. Although there were no clinical signs of bleeding, peri-operative administration of rFVIIa was recommended by the hematologist (first dose at surgical incision, then 4 h later, then every 12 h until 48 h postoperatively). Intraoperatively, serials of ROTEM analysis were performed to evaluate the effect of rFVIIa administration. No significant effect of rFVIIa was seen on NATEM. Surgery was unremarkable, without any significant blood loss. The patient developed radial artery thrombosis 24 h postoperatively, the arterial line was removed, and rFVIIa was discontinued (PT: 14.6, FVII: C 36%). On POD 3, INR was elevated (3.15, FVII: C 3%). To correct INR, the patient was transfused 8 units of FFP, despite any signs of clinical bleeding. However, INR and FVII: C did not correct and the patient was discharged on POD 7 in a stable condition. CONCLUSIONS Even with FVII: C of 8%, the ROTEM analysis revealed a normal coagulation status. The administration of rFVIIa did not improve the already normal baseline coagulation profile, but rather potentially led to an accelerated coagulation or hypercoagulable state and may have led to the radial artery thrombosis. We endorse the use of viscoelastic testing for hemostasis assessment and factor replacement in congenital FVII deficiency.

Perioperative Viscoelastic Assay Use for Monitoring Coagulation Among US Liver Transplantation Centers.

BACKGROUND: Viscoelastic assay has been used in liver transplantation since 1985 and shown to be beneficial in detecting coagulopathy and to guide transfusion. The objective of this study was to review and evaluate the current uses of viscoelastic assay among US liver transplantation programs. METHODS: Anesthesia program directors at all 137 liver transplantation centers in the United States were contacted via email and asked to complete a 21-item survey. The primary outcome measure was the percentage of viscoelastic assay used in the perioperative management of liver transplantation. Secondary outcome measures were institutional demographics, physician training level, and device demographics. RESULTS: Sixty-one of 137 (46%) centers responded. Liver transplantations were performed in the university setting at 48 of the 61 centers (77%), with a modal value of 11 to 50 liver transplantations a year and 74% in adult patients only. Most of the institutions (n = 57, 92%) had access to either rotational thromboelastometry or thrombelastography during liver transplantation. Most centers (n = 54; 87%) also used viscoelastic monitoring routinely (>60% of the time), including 42 (67.7%) that always used viscoelastic assay intraoperatively during liver transplantation. Thirty-five centers (59%) used it preoperatively, and 51 (84%) used it postoperatively. Most viscoelastic assay users (68%) learned how to use it through self-education and 10.5% learned during their fellowship or from a superuser or colleagues. CONCLUSION: Currently, viscoelastic monitoring is widely available and routinely used in most US liver transplantation centers regardless of university or private practice setting, but training in it is limited. Only 21.1% of respondents reported that they received any type of official training in viscoelastic assay interpretation.

Continuation of Angiotensin-Converting Enzyme Inhibitors on the Day of Surgery Is Not Associated With Increased Risk of Hypotension Upon Induction of General Anesthesia in Elective Noncardiac Surgeries.

OBJECTIVE: The aim of this study was to find out whether the preoperative continuation of angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) treatment is associated with intraoperative hypotension immediately after induction of general anesthesia in elective noncardiac surgeries. DESIGN: Retrospective cohort study. SETTING: Single institutional university hospital. PARTICIPANTS: Four hundred patients who underwent elective noncardiac surgery under general anesthesia, with ACE-I or ARB on their list of preoperative home medications, were included. INTERVENTION: Preoperative ACE-I and ARB use was evaluated, and patients were divided into an ACE-I/ARB group versus non-ACE-I/ARB group. MEASUREMENTS: The primary outcome measure was intraoperative hypotension after induction of general anesthesia. The secondary outcome measure was preoperative medication use, medications taken the morning of surgery, induction medication and dosage, and vasopressor medication use during induction. RESULTS: Three hundred forty-nine patients were included for final analysis. The mean admission American Society of Anesthesiologists status was 2.7 ± 0.5, age 65 ± 11 years, and body mass index 31 ± 6.9 kg/m2. There were no statistically significant changes between the no ACE-I/ARB group and the ACE-I/ARB group in systolic blood pressure (p = 0.853), diastolic blood pressure (p = 0.357), and heart rate (p = 0.220) change over the 15 minutes. There was no statistical difference in induction medication dose (propofol, fentanyl, and rocuronium) and pressor use (p = 0.137) for hypotension between the 2 groups. Statistically significant hypotension (p < 0.001) occurred in both groups equally over 15 minutes. CONCLUSION: Continuation of ACE-I/ARB on the day of surgery was not associated with increased risk of intraoperative hypotension upon induction and within 15 minutes of general anesthesia in elective noncardiac surgeries.

Emergent airway management outside of the operating room - a retrospective review of patient characteristics, complications and ICU stay.

BACKGROUND: Emergent airway management outside of the operating room is a high-risk procedure. Limited data exists about the indication and physiologic state of the patient at the time of intubation, the location in which it occurs, or patient outcomes afterward. METHODS: We retrospectively collected data on all emergent airway management interventions performed outside of the operating room over a 6-month period. Documentation included intubation performance, and intubation related complications and mortality. Additional information including demographics, ASA-classification, comorbidities, hospital-stay, ICU-stay, and 30-day in-hospital mortality was obtained. RESULTS: 336 intubations were performed in 275 patients during the six-month period. The majority of intubations (n = 196, 58%) occurred in an ICU setting, and the rest 140 (42%) occurred on a normal floor or in a remote location. The mean admission ASA status was 3.6 ± 0.5, age 60 ± 16 years, and BMI 30 ± 9 kg/m2. Chest X-rays performed immediately after intubation showed main stem intubation in 3.3% (n = 9). Two immediate (within 20 min after intubation) intubation related cardiac arrest/mortality events were identified. The 30-day in-hospital mortality was 31.6% (n = 87), the overall in-hospital mortality was 37.1% (n = 102), the mean hospital stay was 22 ± 20 days, and the mean ICU-stay was 14 days (13.9 ± 0.9, CI 12.1-15.8) with a 7.3% ICU-readmission rate. CONCLUSION: Patients requiring emergent airway management are a high-risk patient population with multiple comorbidities and high ASA scores on admission. Only a small number of intubation-related complications were reported but ICU length of stay was high.

Exchange Autotransfusion for Rapid Correction of Hyperkalemia During Liver Transplantation: A Case Report.

A 46-year-old woman with alcoholic cirrhosis and hepatorenal syndrome requiring hemodialysis presented with hyperkalemia (5.5 mEq/L) immediately before liver transplantation. For correction of hyperkalemia, an exchange transfusion began by removing her blood into an autotransfusion system to wash out noncellular components while maintaining normovolemia. Additionally, she received washed homologous red blood cells, insulin, and glucose to minimize or reduce the degree of hyperkalemia. Serum potassium level decreased to 4.0 mEq/L within 3 hours and was 5.0 mEq/L 30 seconds after reperfusion of the grafted liver. Postreperfusion syndrome was not observed. In summary, exchange transfusion was used successfully for rapid correction of hyperkalemia, showing the value of its application in liver transplantation.

Intraoperative Diagnosis and Management of Acute Hypotensive Blood Transfusion Reaction (AHTR): A Report of Two Cases.

BACKGROUND Acute hypotensive transfusion reaction (AHTR) is characterized by the abrupt onset of hypotension immediately after the start of transfusion and usually resolves when transfusion ceases. Recent studies have shown an association with pre-operative treatment with an angiotensin-converting enzyme (ACE) inhibitor. This report presents two cases of AHTR in non-related patients and describes the diagnosis and management. CASE REPORT A 68-year-old woman underwent lumbar fusion surgery due to spinal stenosis and an 86-year-old man underwent a pancreaticoduodenectomy (Whipple's procedure). Both patients had been treated pre-operatively with ACE inhibitors for hypertension. During surgery, both patients experienced acute profound intraoperative hypotension immediately after transfusion of packed red blood cells (RBCs). The blood transfusion was stopped immediately, and hemodynamic support was given with epinephrine, ephedrine, and phenylephrine. A diagnosis of acute hemolytic transfusion reaction was excluded by the direct antiglobulin test, serum hemolysis testing, exclusion of blood group mismatching, and a post-transfusion antibody screen. Other causes of hypotension were excluded. The two patients were confirmed t have had an AHTR, based on the current Centers for Disease Control and Prevention (CDC) criteria. In both cases, discontinuation of surgery was not possible, and surgery continued with intermittent hemodynamic support provided with catecholamines and vasopressin. CONCLUSIONS AHTR is a diagnosis of exclusion, based on laboratory and clinical findings. Antibody-mediated acute hemolytic transfusion reaction and any other causes of hypotension should be excluded as rapidly as possible. Patients who are at high risk of intraoperative bleeding might benefit from cessation of ACE inhibitors pre-operatively.

Bilateral Superficial Femoral Artery Thrombosis in a 15-Year-Old Caucasian Male with Homozygous Prothrombin G20210A Genotype and Associated Antiphospholipid Syndrome.

Prothrombin mutation was usually associated with other well-established predisposing factors for venous thrombosis such as antiphospholipid antibodies. Recently, even isolated prothrombin gene mutation G20210A has been reported to present severe or unusual vein thrombosis. Less clear is the role of prothrombin mutation in the formation of arterial thrombosis. We present a case of a 15-year-old healthy White male with acute bilateral femoral artery thrombosis. The patient presented with increasing left leg pain for about 1 week. He was a physically very active teenager with a new onset of leg pain aggravated by exercise. Physical examination revealed a pale and cold left foot with dorsal foot necrosis (2 × 2 cm) that started 2 days ago. In addition, he complained of moderate rest pain. No symptoms were noticed on the right lower extremity. The ankle brachial index was 0.3 on the left and 0.6 on the right. Duplex sonography showed bilateral superficial femoral artery thrombosis, which was confirmed by angiography. Subsequently, he undergoes left superficial femoral and popliteal artery lysis with rt-PA (Actilyse boehringer ingelheim, Ingelheim am Rhein, Germany) and full heparinization. Treatment was discontinued after 24 hours with no significant improvement of symptoms. Full anticoagulation with Coumadin (Bristol-Myers Squibb Company, New York, NY) and alprostadil (Prostavasin UCB, Brussels, Belgium) infusion for 2 weeks was initiated and eventually patient's symptoms improved. Laboratory testing revealed a homozygous prothrombin G20210A mutation and antiphospholipid syndrome. Homozygous prothrombin G20210A mutation in conjunction with antiphospholipid syndrome is a rare combination of coagulation disorder. Early intervention with full anticoagulation and subsequent lifelong anticoagulation should be considered in treatment strategy.

Early Amiodarone-Induced Pulmonary Toxicity after Endovascular Aneurysm Repair: A Case Report.

Amiodarone is an antiarrhythmic drug that has been commonly used to treat supraventricular and ventricular arrhythmias. This drug is an iodine-containing compound that tends to accumulate in several organs, including the lungs. Especially, its main metabolically active metabolite desethylamiodarone can adversely affect many organs. A very well-known severe complication of amiodarone therapy is the amiodarone-induced pulmonary toxicity. This article presents the case study of an 82-year-old male patient with acute amiodarone-induced pulmonary toxicity. The patient underwent endovascular aneurysm repair for rapidly increasing abdominal aortic aneurysm. During the postoperative period the patient developed rapid atrial fibrillation and amiodarone therapy was initiated. Subsequently, the patient went into acute respiratory failure and was requiring high supplemental oxygen support and a chest X-ray revealed bilateral pulmonary infiltrates. During the hospital course the patient required mechanical ventilator support. With discontinuation of amiodarone, supportive therapy and steroid treatment patient symptoms significantly improved. Amiodarone-induced pulmonary toxicity must be considered in the differential diagnosis of all patients on the medication with progressive or acute respiratory symptoms. Early discontinuation of amiodarone and aggressive corticosteroid therapy should be considered as a viable treatment strategy.