A comparison of right and left lobectomies for living donor liver transplantation: an anesthesiologist's point of view.

Because of the shortage of cadaveric donor organs, living donor liver transplantation (LDLT) has become an established therapy modality for end-stage liver disease. Based on recipient size, both right and left liver lobe grafts have been used successfully in LDLT. The aim of this study was to compare the risk of intraoperative complications and transfusion requirements between right and left lobe donors. We reviewed the charts of 54 right lobe (Group RL), 29 left lobe (Group LL), and 31 left lateral segment (Group LLS) donors who underwent lobectomy from January 2003 through January 2007. We recorded patient demographics, perioperative laboratory values, intraoperative fluid and transfusion requirements, intraoperative hemodynamic parameters, and complications. Demographic features and preoperative laboratory values were similar for the 3 groups, except for age (Group RL, 37.3 +/- 8.7; Group LL, 36.0 +/- 9.3; Group LLS, 31.7 +/- 9.4; P = .02). There were no significant differences in mean liver volumes among the groups (P > .05). Respective graft volumes were 803.1 +/- 139.2 mL, 438.0 +/- 122.7 mL, and 308.2 +/- 76.6 mL for Groups RL, LL, and LLS, respectively (P < .001). More patients in Group LLS required heterologous blood transfusion than did those in the other groups (P = .01). The incidence of intraoperative hypotension was similar for all groups (P > .05). Group RL had a significantly higher rate of intraoperative hypothermia than the other groups (P = .01). There were no intraoperative respiratory complications or cardiac events. These results indicated that both right and left donor lobectomies for LDLT were safe procedures with acceptable rates of minor intraoperative complications.

Dexmedetomidine causes prolonged recovery when compared with midazolam/fentanyl combination in outpatient shock wave lithotripsy.

BACKGROUND AND OBJECTIVES: Analgesia and sedation are usually required during extracorporeal shock wave lithotripsy. In the present study, the recovery time and effectiveness of sedation and analgesia of dexmedetomidine was compared with a midazolam/fentanyl combination in outpatient extracorporeal shock wave lithotripsy. METHODS: Forty-nine patients scheduled for outpatient extracorporeal shock wave lithotripsy were randomly assigned to two groups: a dex group (n = 25; dexmedetomidine 1 microg kg(-1) loading dose followed by dexmedetomidine 0.2 microg kg(-1) h(-1) and a control group (n = 24; midazolam 0.05 mg kg(-1) and fentanyl 1 microg kg(-1)). Recovery time, rescue analgesics (fentanyl 25 microg) and sedatives (midazolam 1 mg), and patients' satisfaction rates were recorded. RESULTS: The two groups were similar regarding patient characteristics and procedure-related details (P > 0.05). Recovery time was significantly prolonged in the dex group when compared with the control group (116.4 +/- 39.3 vs. 50.8 +/- 19.8 min, respectively, P < 0.001). The percentage of patients requiring rescue doses of fentanyl and the applied doses were significantly higher in the dex group than in the control group (96% vs. 67%, P = 0.01; and 69.0 +/- 31.7 vs. 38.8 +/- 42.9 microg, respectively, P = 0.007). More patients in the dex group received rescue midazolam (96% vs. 58%, P = 0.002). More patients in the control group were highly satisfied with their sedation/analgesia (83% vs. 56%, P = 0.038). CONCLUSION: Dexmedetomidine was associated with a longer recovery time than a midazolam/fentanyl combination when used for sedation and analgesia during outpatient extracorporeal shock wave lithotripsy in this study. The incidence of rescue sedative and analgesic need was also significantly higher when dexmedetomidine was used.

Predictors of immediate tracheal extubation in the operating room after liver transplantation.

Immediate postoperative extubation may reduce the incidence of postoperative respiratory complications after orthotopic liver transplantation (OLT). We evaluated the predictors of immediate tracheal extubation in the operating room (OR) in our patients by retrospectively reviewing data from all patients who underwent OLT between January 2004 and June 2006. The patients were divided into two groups according to whether they had undergone extubation in the OR (group 1 n=52) or in the intensive care unit (ICU; group 2 n=48). When compared with the patients in group 2, those in group 1 had lower mean preoperative serum creatinine levels (0.9 +/- 1 vs 0.6 +/- 0.3 mg/dL, P=.04) and intraoperative transfusion requirements (packed red blood cells, 35.5 +/- 29.8 vs 25.6 +/- 19.0 mL/kg; P=.05, and fresh frozen plasma, 33.1 +/- 15.6 vs 25.7 +/- 14.3 mL/kg; P=.01). The incidence of intraoperative hypotension and emergent OLT was significantly greater in group 2 than group 1 (33.3% vs 13.5%, P=.01 and 45.8% vs 21.2%, respectively, P=.009). On logistic regression analysis, only emergent OLT (P=.009, odds ratio = 3.5) and intraoperative hypotension (P=.018, odds ratio = 3.7) were significantly associated with a lower probability of immediate postoperative extubation in the OR. Our results suggested that hemodynamic stability and elective OLT were predictors of successful immediate tracheal extubation in the OR.

Effect of the interval between organ donor brain death and organ harvesting on kidney graft function after transplantation.

We hypothesized that providing a longer resuscitation period (>12 hours) for a brain-dead organ donor (BDOD) to attenuate the detrimental effects of sympathetic discharge that occur during this event would improve graft function. We reviewed the medical records of patients who had received a kidney transplant from a BDOD between November 2001 and June 2006. The patients were divided into two groups according to whether the interval between the brain death of the organ donor and organ harvest was >12 hours (group 1 n=12) or .05). When compared with patients in group 2, those in group 1 demonstrated a significant trend toward improved renal graft function in terms of serum creatinine levels, BUN levels, and urine output. Five patients in group 2 and two patients in group 1 required hemodialysis during the early posttransplantation period (P>.05). Our results indicate that longer in situ resuscitation of the graft kidney in BDODs may improve posttransplant function.

Respiratory problems in renal transplant recipients admitted to intensive care during long-term follow-up.

Cardiovascular disease, malignancies, and infectious complications are major causes of morbidity and mortality of renal transplant recipients. Mortality rates vary between 16% and 40% in an intensive care unit (ICU). The aims of this study were to identify the types incidences of respiratory problems that affected renal transplant recipients admitted to the ICU during long-term follow-up thereby determining the impact of respiratory problems on mortality. We reviewed the data for 34 recipients who had 39 ICU admissions from January 2000 through December 2003. Twenty-four admissions (61.5%) had at least one respiratory problem at admission or developed at least one during the ICU stay. The most frequent problem was pneumonia (n=18, 46.2% of the 39 readmissions), followed by acute respiratory failure (n=10, 25.6%), atelectasis (n=9, 23.1%), pleural effusion (n=8, 20.5%), and pulmonary edema (n=2, 5.1%). The patients who had respiratory problems showed a significantly higher mortality rate than those who did not have respiratory problems (66.6% versus 26.6%, respectively; P<.05). The overall mortality rate was 58.8% (20 patients). Thus, infectious and respiratory problems are the most frequent indications for admission and the most common problems during an ICU stay. The prognosis for patients who either have a respiratory problem upon admission to the ICU or develop one during the ICU stay is poor.

Successful treatment of a child with fulminant liver failure and coma due to Amanita phalloides poisoning using urgent liver transplantation.

Intoxication due to eating wild mushrooms presents with a variety of signs, ranging from mild diarrhea to severe organ failure. We present the case of an 11-year-old boy with fulminant liver failure and hepatic coma due to Amanita phalloides poisoning treated with an urgent pediatric orthotopic liver transplantation. Successful treatment of patients with fulminant liver failure and hepatic coma caused by Amanita phalloides poisoning is possible using urgent orthotopic liver transplantation when conservative medical treatment modalities are ineffective.

Pulse contour cardiac output system use in pediatric orthotopic liver transplantation: preliminary report of nine patients.

Anesthetic management of orthotopic liver transplantation (OLT) in pediatric patients is challenging in terms of intraoperative bleeding, fluid management, and hemodynamic monitoring. The pulse contour cardiac output (PiCCO) system, a relatively new device based on the single-indicator transaortic thermodilution technique, may be useful for intraoperative hemodynamic monitoring in pediatric patients. This is a preliminary report of PiCCO use in nine children (aged 9.8 +/- 4.7 years) undergoing OLT. Hemodynamic volumetric parameters monitored by the PiCCO system were mean arterial pressure (MAP), cardiac index (CI), intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), systemic vascular resistance index (SVRI), and stroke volume variability (SVV). All parameters were recorded at anesthesia induction (T0), at the end of the anhepatic phase (Tanhepatic), and at the end of operation (Tend). The PiCCO system revealed similar MAP, CI, EVLWI, SVV, and SVRI values at all measurement intervals. Despite similar central venous pressure measurements, ITBVI values indicated significantly lower values at Tanhepatic than at T0 (627 +/- 160 mL/m2 and 751 +/- 151 mL/m2, respectively, P = .013). There were no PiCCO catheter-related complications in any patient. These findings demonstrate that the PiCCO system is a safe, continuous, multiparameter invasive monitoring device for use in pediatric patients undergoing OLT. This system may provide valuable data during pediatric OLT and appears to be a promising monitoring tool in these patients.

Internal jugular versus subclavian vein catheterization for central venous catheterization in orthotopic liver transplantation.

The aim of this study was to compare incidence rates of mechanical and infectious complications associated with central venous catheterization via the internal jugular vein (IJV) versus the subclavian vein (SV) among 45 consecutive patients undergoing orthotopic liver transplantation (OLT) between January 2000 and June 2004. The subjects were divided into two groups according to the site of central venous catheterization (IJV or SV). We recorded each patient's physical characteristics, international normalized ratio (INR), partial thromboplastin time, platelet levels, number of puncture attempts, success/failure of central venous catheterization, duration of catheter placement, occurrence of catheter tip misplacement, arterial puncture, incidence of hematoma or pneumothorax, catheter-related infection, or bacterial colonization of the catheter. Senior staff anesthesiologists performed 22 SV and 23 IJV catheterizations for the 45 OLT procedures. The SV and IVJ groups both had minor coagulation abnormalities with slightly increased INR values at the time of catheterization. There were no significant differences between the groups with respect to success of central venous catheterization (100% for both), numbers of attempted punctures, duration of catheter placement, and incidence rates of mechanical and infectious complications. Both groups showed high frequencies of catheter tip misplacement, with right atrium as the site of misplacement in all cases. Two patients in the IJV group (8.7%) developed hematomas after accidental carotid artery puncture. The results suggest that, when performed by experienced anesthesiologists, central venous catheterization via the SV is an acceptable alternative to IJV catheterization for patients undergoing OLT.

Early postoperative pulmonary complications after heart transplantation.

OBJECTIVE: The aim of this study was to determine the types, incidence, and risk factors for early postoperative pulmonary complications in heart transplant recipients. METHODS: We retrospectively collected data from the records of consecutive heart transplantations from January 2003 to December 2013. A total of 83 patients underwent heart transplantation. The data collected for each case were demographic features, duration of mechanical ventilation, respiratory problems that developed during the intensive care unit (ICU) stay, and early postoperative mortality (<30 d). RESULTS: Of the 72 patients considered, 52 (72.2%) were male. The overall mean age at the time of transplantation was 32.1 ± 16.6 years. Twenty-five patients (34.7%) developed early postoperative respiratory complications. The most frequent problem was pleural effusion (n = 19; 26.4%), followed by atelectasis (n = 6; 8.3%), acute respiratory distress syndrome (n = 5; 6.9%), pulmonary edema (n = 4; 5.6%), and pneumonia (n = 3; 4.2%). Postoperative duration of mechanical ventilation (44.2 ± 59.2 h vs 123.8 ± 190.8 h; P = .005) and the length of postoperative ICU stay (10.1 ± 5.8 h vs 19.8 ± 28.9 h; P = .03) were longer among patients who had respiratory problems. Postoperative length of stay in the hospital (22.3 ± 12.5 d vs 30.3 ± 38.3 d; P = .75) was similar in the 2 groups. The overall mortality rate was 12.5% (n = 9). The patients who had respiratory problems did not show higher mortality than those who did not have respiratory problems (16.0% vs 10.6%; P = .71). CONCLUSIONS: Respiratory complications were relatively common in our cohort of heart transplant recipients. However, these complications were mostly self-limiting and did not result in worse mortality.

Early postoperative complications of pediatric liver transplantation: experience at one center.

To evaluate the postoperative complications within the first month among 20 pediatric liver transplant recipients between April 1990 and March 2003 we retrospectively studied their medical charts to gather demographic data; primary diagnosis; operative duration; perioperative transfusions; time to extubation; length of intensive care unit (ICU) stay; mortality; perioperative laboratory values; and postoperative complications including respiratory, infections, renal, neurological, cardiovascular, and gastrointestinal tract (GIT) complications. Ten male and ten female patients of mean age 8 +/- 4 years had a mean operative duration, time to extubation, and length of stay in the ICU of 12.1 +/- 2.3 hours, 11.1 +/- 15.0 hours, and 7.2 +/- 5.5 days, respectively. The most frequent postoperative complication was respiratory (n = 14, 70%), followed by infections (n = 13, 65%), renal (n = 8, 40%), neurological (n = 7, 35%), cardiovascular (n = 4, 20%), and GIT (n = 4, 20%) infections. The overall mortality rate was 25% (n = 5). Compared with patients who survived, those who died displayed significantly lower perioperative platelet counts (P <.05), as well as a significantly higher incidence of postoperative neurological disorders (P =.031), and cardiovascular complications (P =.032).

Percutaneous dilational tracheotomy in solid-organ transplant recipients.

Pulmonary complications, such as pneumonia and respiratory failure, are important contributors to posttransplantation morbidity and mortality among solid-organ transplant recipients. Percutaneous dilational tracheotomy (PDT) is cost-effective in critically ill patients who require prolonged mechanical ventilation; however, the literature lacks reports about the effectiveness of this procedure in organ transplant recipients. Between August 2001 and February 2003, five recipients underwent PDT in our intensive care unit: two kidney, two liver, and one heart transplant recipient. The respective mean values for age, weight and APACHE II score were 41 +/- 7 yrs (range, 33-51 years), 63 +/- 14 kg (range, 40-80 kg), and 23 +/- 9 (range, 15-35). All PDTs were performed at the bedside by an experienced staff anesthesiologist under endoscopic guidance using the Griggs forceps dilational technique. The mean interval from transplantation to PDT was 58 +/- 56 months (range, 8 days to 132 months). In all cases, the indication for PDT was prolonged mechanical ventilation due to acute respiratory failure. The mean duration of endotracheal intubation before PDT was 4 +/- 3 days (range, 1-8 days). Transient hypoxemia (n = 1) and mild extratracheal bleeding (n = 1) were the only early complications. There were no late complications (including peristomal infection) or deaths associated with the procedures. Among the two patients who survived their stay in the intensive care unit, the functional and cosmetic outcomes of PDT were excellent. We recommend this technique for prolonged airway management in solid-organ transplant recipients.

Risk factors for postoperative respiratory complications in adult liver transplant recipients.

To determine the types and the incidence of as well as risk factors for early postoperative (<30 days) respiratory complications in adult liver transplant (LT) recipients, we reviewed The data of 44 consecutive adult LT recipients who received their grafts from January 1995 through December 2002. The data included demographic features; primary diagnosis; number of intraoperative transfusions; preoperative and postoperative laboratory values; intraoperative and postoperative characteristics; and early postoperative (<30 days) mortality. Pulmonary atelectasis, pleural effusion, pneumonia, respiratory failure, and pulmonary edema were the respiratory complications investigated. Twenty-six patients (59.1%) developed at least one respiratory complication during the early postoperative period. The most frequent complication was pleural effusion (n = 18, 40.9%), followed by atelectasis (n = 13, 29.5%), pneumonia (n = 10, 22.7%), acute respiratory failure (n = 5, 11.4%), pulmonary edema (n = 3, 6.8%), and pneumothorax (n = 2, 4.5%). Compared to the patients who did not develop these problems, the affected cohort was significantly older (27 +/- 12 years vs 36 +/- 14 years, respectively; P =.039) and required more intraoperative transfusions (P =.005). Among the overall mortality rate of 15.9%, patients who developed pneumonia showed a significantly higher mortality (40.0% vs 8.8%, respectively; P =.037). Pleural effusion, atelectasis, and pneumonia are the main respriatory complications that occur in adult LT recipients. Patient age and intraoperative transfusion requirements are important predictors of early postoperative complications. Pneumonia is associated with a poor prognosis in this patient group.

RIFLE criteria for acute kidney dysfunction following heart transplantation: incidence and risk factors.

BACKGROUND AND PURPOSE: There are few data regarding the occurrence of (RIFLE)-based acute kidney dysfunction (AKD) after heart transplantation (HT) and its risk factors. The aim of this study was to apply RIFLE criteria in patients who developed AKD following HT to compare patients with and without AKD and to determine incidence and risk factors of AKD. PATIENTS AND METHODS: We retrospectively analyzed the records of 65 patients who underwent HT between 2003 and 2012. We investigated 3 levels of renal dysfunction outlined in RIFLE criteria: risk (R), injury (I), and failure (F). Appropriate class was assigned comparing baseline creatinine level to peak levels in the first 7 days after HT. Perioperative variables of heart transplant recipients were collected. RESULTS: The mean age at transplantation was 32.8 ± 16.6 years with 72.7% males. The incidence of AKD was 61%, risk occured in 18%, injury in 16%, and failure in 27% of the patients. Patients who had AKD were significantly older (37.9 ± 15.6 vs 24.6 ± 15.0 years: P = .008), had higher body mass index (24.7 ± 6.7 vs 18.6 ± 4.3; P = .002), and more frequently had history of hypertension (92% vs 8%; P = .011) and smoking (100% vs 0%; P = .008) when compared with those who did not have AKD. When compared with patients who did not develop AKD postoperatively, preoperative higher creatinine levels (1.1 ± 0.3 vs 0.8 ± 0.4; P = .025), intraoperative higher mean arterial pressures (99.2 ± 14.1 vs 89.0 ± 11.4 mm Hg; P = .011), a higher frequency of intraoperative acidosis (81% vs 19%; P = .041), higher lactate levels (5.1 ± 3.8 vs 2.8 ± 1.7 mmol/L; P = .038), and postoperative more frequent use of cyclosporine (91% vs 9%; P = .025) were seen in those who developed AKD. Logistic regression analysis revealed that age (odds ratio [OR], 1.057; 95% confidence interval [CI], 1.010-1.106; P = .018) and use of cyclosporine (OR, 0.099; 95% CI, 0.010-0.935; P = .043) were independent risk factors for AKD. CONCLUSIONS: Our results suggest that based on RIFLE criteria, AKD occur in more than half of HTs postoperatively. Older age and use of cyclosporine are associated with AKD following HT.

Early-onset posterior reversible encephalopathy syndrome after solid organ transplantation in pediatric patients: a report of 2 cases.

Posterior reversible encephalopathy syndrome (PRES) is a neurological disturbance that occurs due to different reasons and presents with different clinical symptoms. It can be a devastating situation, but, timely treatment may lead to complete recovery. We report 2 cases of PRES, which developed and fully recovered in the early period after solid organ transplantation in pediatric patients.