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1.
Clin Transplant ; 37(10): e15057, 2023 10.
Artigo em Inglês | MEDLINE | ID: mdl-37350743

RESUMO

BACKGROUND: The post-operative course after Liver Transplantation (LT) can be complicated by early allograft dysfunction (EAD), primary nonfunction (PNF) and death. A lactate concentration at the end of transplant of ≥5 mmol/L was recently proposed as a predictive marker of PNF, EAD, and mortality; this study aimed to validate these previous reports in a large single center cohort. METHODS: This retrospective cohort study included adult liver transplant recipients who received grafts from deceased donors at our center between June 2012 and May 2021. Receiver operating characteristic (ROC) curves for the lactate concentration at the end of transplantation were computed to determine the AUC for PNF, EAD and mortality at 90 days. RESULTS: In our cohort of 1137 cases, the AUCs for lactate to predict EAD, PNF and mortality were respectively .56 (95% confidence interval [CI]: .53-.60), .69 (95% CI: .52-.85), and .74 (95% CI: .63-.84). CONCLUSION: The clinical value of lactate concentration at the end of transplantation to predict PNF, EAD and mortality at 90 days was, at best, modest, as shown by the relatively low AUCs. Our findings cannot validate previous reports that the lactate level alone is a good predictor of poor outcomes after liver transplantation.


Assuntos
Transplante de Fígado , Disfunção Primária do Enxerto , Adulto , Humanos , Transplante de Fígado/efeitos adversos , Ácido Láctico , Estudos Retrospectivos , Sobrevivência de Enxerto , Transplante Homólogo , Aloenxertos , Disfunção Primária do Enxerto/etiologia , Fatores de Risco
2.
Cardiovasc Ultrasound ; 20(1): 6, 2022 Mar 24.
Artigo em Inglês | MEDLINE | ID: mdl-35331262

RESUMO

BACKGROUND: Septic shock is a severe form of sepsis marked by hypotension with an ominous outcome despite the introduction of modern intensive care. The aim of the present study is to obtain a panel with biomarkers, echocardiographic and vascular parameters to better risk stratify patients and identify those at higher risk of ominous outcome. METHODS: Between May 2013 and April 2016, 35 consecutive patients admitted at the Intensive Care Unit (ICU) of ASST Great Metropolitan Hospital Niguarda with the diagnosis of severe sepsis or septic shock were enrolled. All patients underwent rest echocardiography and several circulating biomarkers of myocardial damage or oxidative stress. RESULTS: The multivariate Cox's proportional hazard model showed that the only independent prognostic predictor for 30-day mortality was the angiopoietin-2, (HR 1.017, 95% CI 1.000-1.034; P = 0.049). An angiopoietin-2 concentrations ≥ of 33,418 pg/mL was identified as the optimal threshold for the discrimination between survivors and non survivors at the time of admission in ICU, with a sensitivity of 80% and a specificity of 68%. CONCLUSIONS: Septic shock has a poor in-hospital outcome even when the best of care is implemented. Among the biochemical parameters angiopoietin was able to identify patients at risk of death. The lowest the value at admission, the highest the risk of in-hospital death. No echocardiographic nor vascular parameter was able to predict outcome in this setting.


Assuntos
Sepse , Choque Séptico , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Projetos Piloto , Choque Séptico/diagnóstico
3.
Clin Infect Dis ; 73(9): 1664-1676, 2021 11 02.
Artigo em Inglês | MEDLINE | ID: mdl-33618353

RESUMO

BACKGROUND: A growing body of observational evidence supports the value of ceftazidime-avibactam (CAZ-AVI) in managing infections caused by carbapenem-resistant Enterobacteriaceae. METHODS: We retrospectively analyzed observational data on use and outcomes of CAZ-AVI therapy for infections caused by Klebsiella pneumoniae carbapenemase-producing K. pneumoniae (KPC-Kp) strains. Multivariate regression analysis was used to identify variables independently associated with 30-day mortality. Results were adjusted for propensity score for receipt of CAZ-AVI combination regimens versus CAZ-AVI monotherapy. RESULTS: The cohort comprised 577 adults with bloodstream infections (n = 391) or nonbacteremic infections involving mainly the urinary tract, lower respiratory tract, and intra-abdominal structures. All received treatment with CAZ-AVI alone (n = 165) or with ≥1 other active antimicrobials (n = 412). The all-cause mortality rate 30 days after infection onset was 25% (146/577). There was no significant difference in mortality between patients managed with CAZ-AVI alone and those treated with combination regimens (26.1% vs 25.0%, P = .79). In multivariate analysis, mortality was positively associated with presence at infection onset of septic shock (P = .002), neutropenia (P < .001), or an INCREMENT score ≥8 (P = .01); with lower respiratory tract infection (LRTI) (P = .04); and with CAZ-AVI dose adjustment for renal function (P = .01). Mortality was negatively associated with CAZ-AVI administration by prolonged infusion (P = .006). All associations remained significant after propensity score adjustment. CONCLUSIONS: CAZ-AVI is an important option for treating serious KPC-Kp infections, even when used alone. Further study is needed to explore the drug's seemingly more limited efficacy in LRTIs and potential survival benefits of prolonging CAZ-AVI infusions to ≥3 hours.


Assuntos
Infecções por Klebsiella , Klebsiella pneumoniae , Adulto , Antibacterianos/uso terapêutico , Compostos Azabicíclicos/uso terapêutico , Proteínas de Bactérias , Ceftazidima/uso terapêutico , Combinação de Medicamentos , Humanos , Infecções por Klebsiella/tratamento farmacológico , Testes de Sensibilidade Microbiana , Estudos Retrospectivos , beta-Lactamases
4.
Mycoses ; 63(12): 1299-1310, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32810888

RESUMO

OBJECTIVES: Rapid and reliable exclusion of invasive fungal infections (IFI) by markers able to avoid unnecessary empirical antifungal treatment is still a critical unmet clinical need. We investigated the diagnostic performance of a newly available ß-d-Glucan (BDG) quantification assay, focusing on the optimisation of the BDG cut-off values for IFI exclusion. METHODS: BDG results by Wako ß-glucan assay (lower limit of detection [LLOD] = 2.16 pg/mL, positivity ≥ 11 pg/mL) on two consecutive serum samples were retrospectively analysed in 170 patients, admitted to haematological wards (N = 42), intensive care units (ICUs; N = 80), or other wards (N = 48), exhibiting clinical signs and/or symptoms suspected for IFI. Only patients with proven IFI (EORTC/MSG criteria) were considered as true positives in the assessment of BDG sensitivity, specificity and predictive values. RESULTS: Patients were diagnosed with no IFI (69.4%), proven IFI (25.3%) or probable IFI (5.3%). Two consecutive BDG values < LLOD performed within a median of 1 (interquartile range: 1-3) day were able to exclude a proven IFI with 100% sensitivity and negative predictive value (primary study goal). Test's specificity improved by using two distinct positivity and negativity cut-offs (7.7 pg/mL and LLOD, respectively), but remained suboptimal in ICU patients (50%), as compared to haematological or other patients (93% and 90%, respectively). CONCLUSIONS: The classification of Wako's results as negative when < LLOD, and positive when > 7.7 pg/mL, could be a promising diagnostic approach to confidently rule out an IFI in both ICU and non-ICU patients. The poor specificity in the ICU setting remains a concern, due to the difficulty to interpret positive results in this fragile population.


Assuntos
Testes Diagnósticos de Rotina/métodos , Infecções Fúngicas Invasivas/diagnóstico , beta-Glucanas/sangue , Idoso , Antifúngicos/uso terapêutico , Caspofungina/uso terapêutico , Feminino , Fluconazol/uso terapêutico , Humanos , Unidades de Terapia Intensiva , Infecções Fúngicas Invasivas/tratamento farmacológico , Limite de Detecção , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Voriconazol/uso terapêutico
5.
BMC Anesthesiol ; 20(1): 31, 2020 01 30.
Artigo em Inglês | MEDLINE | ID: mdl-32000668

RESUMO

BACKGROUND: Jehovah's Witnesses represent a tremendous clinical challenge when indicated to liver transplantation because they refuse blood transfusion on religious grounds and the procedure is historically associated with potential massive peri-operative blood loss. We herein describe a peri-operative management pathway with strategies toward a transfusion-free environment with the aim not only of offering liver transplant to selected Jehovah's Witnesses patients but also, ultimately, of translating this practice to all general surgical procedures. METHODS: This is a retrospective review of prospective medical records of JW patients who underwent LT at our Institution. The peri-operative multimodal strategy to liver transplantation in Jehovah's Witnesses includes a pre-operative red cell mass optimization package and the intra-operative use of normovolemic haemodilution, veno-venous bypass and low central venous pressure. RESULTS: In a 9-year period, 13 Jehovah's Witness patients received liver transplantation at our centre representing the largest liver transplant program from deceased donors in Jehovah's Witnesses patients reported so far. No patient received blood bank products but 3 had fibrinogen concentrate and one tranexamic acid to correct ongoing hyper-fibrinolysis. There were 4 cases of acute kidney injury (one required extracorporeal renal replacement treatment) and one patient needed vasoactive medications to support blood pressure for the first 2 postoperative days. Two patients underwent re-laparotomy. Finally, of the 13 recipients, 12 were alive at the 1 year follow-up interview and 1 died due to septic complications. CONCLUSIONS: Our experience confirms that liver transplantation in selected Jehovah's Witnesses patients can be feasible and safe provided that it is carried out at a very experienced centre and according to a multidisciplinary approach.


Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Testemunhas de Jeová , Transplante de Fígado/métodos , Assistência Perioperatória/métodos , Religião e Medicina , Adulto , Pressão Venosa Central/fisiologia , Feminino , Hemodiluição/métodos , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos
6.
Clin Infect Dis ; 68(3): 355-364, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-29893802

RESUMO

Background: Ceftazidime-avibactam (CAZ-AVI) has been approved in Europe for the treatment of complicated intra-abdominal and urinary tract infections, as well as hospital-acquired pneumonia, and for gram-negative infections with limited treatment options. CAZ-AVI displays in vitro activity against Klebsiella pneumoniae carbapenemase (KPC) enzyme producers, but clinical trial data on its efficacy in this setting are lacking. Methods: We retrospectively reviewed 138 cases of infections caused by KPC-producing K. pneumoniae (KPC-Kp) in adults who received CAZ-AVI in compassionate-use programs in Italy. Case features and outcomes were analyzed, and survival was then specifically explored in the large subcohort whose infections were bacteremic. Results: The 138 patients started CAZ-AVI salvage therapy after a first-line treatment (median, 7 days) with other antimicrobials. CAZ-AVI was administered with at least 1 other active antibiotic in 109 (78.9%) cases. Thirty days after infection onset, 47 (34.1%) of the 138 patients had died. Thirty-day mortality among the 104 patients with bacteremic KPC-Kp infections was significantly lower than that of a matched cohort whose KPC-Kp bacteremia had been treated with drugs other than CAZ-AVI (36.5% vs 55.8%, P = .005). Multivariate analysis of the 208 cases of KPC-Kp bacteremia identified septic shock, neutropenia, Charlson comorbidity index ≥3, and recent mechanical ventilation as independent predictors of mortality, whereas receipt of CAZ-AVI was the sole independent predictor of survival. Conclusions: CAZ-AVI appears to be a promising drug for treatment of severe KPC-Kp infections, especially those involving bacteremia.


Assuntos
Antibacterianos/uso terapêutico , Compostos Azabicíclicos/uso terapêutico , Enterobacteriáceas Resistentes a Carbapenêmicos/isolamento & purificação , Ceftazidima/uso terapêutico , Infecções por Klebsiella/tratamento farmacológico , Klebsiella pneumoniae/isolamento & purificação , Terapia de Salvação/métodos , Inibidores de beta-Lactamases/uso terapêutico , Adulto , Idoso , Combinação de Medicamentos , Feminino , Humanos , Itália , Infecções por Klebsiella/microbiologia , Infecções por Klebsiella/mortalidade , Infecções por Klebsiella/patologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
7.
Endoscopy ; 51(12): 1146-1150, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31163496

RESUMO

BACKGROUND: Management of biliary adverse events (BAEs) after biliodigestive anastomosis is challenging. We propose a new endoscopic approach to improve BAEs in this clinical setting. METHODS: Patients who had BAEs after a hepaticojejunostomy with Roux-en-Y loop or a Whipple procedure underwent creation of an entero-enteral endoscopic bypass (EEEB) between the duodenal/gastric wall and the biliary jejunal loop under endoscopic ultrasound (EUS) and fluoroscopic guidance using specifically designed fully covered self-expandable metal stents. RESULTS: 32 consecutive patients underwent EEEB, which was successful in all but one patient. One procedural and five long-term mild adverse events occurred. Endoscopic retrograde cholangiography (ERC) through the EEEB successfully treated all types of BAEs in these patients. Disease recurred in two patients who were successfully re-treated through the EEEB. CONCLUSIONS: Our retrospective study showed that in patients with BAEs after biliodigestive anastomosis, EEEB is safe, feasible, and allows a successful long-term treatment of different BAEs in a tertiary referral center with high-level experience in both endoscopic retrograde cholangiopancreatography and EUS.


Assuntos
Anastomose em-Y de Roux/efeitos adversos , Anastomose Cirúrgica , Procedimentos Cirúrgicos do Sistema Biliar , Colangiopancreatografia Retrógrada Endoscópica/métodos , Endoscopia Gastrointestinal/métodos , Complicações Pós-Operatórias , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Procedimentos Cirúrgicos do Sistema Biliar/efeitos adversos , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Endossonografia/métodos , Feminino , Humanos , Itália , Jejuno/cirurgia , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos
9.
Curr Opin Crit Care ; 20(4): 411-9, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24979712

RESUMO

PURPOSE OF REVIEW: Major improvements in perioperative care and immunobiology have not abated the risk for severe pulmonary complications after solid-organ transplantation. The aim of this study is to update information on infectious and noninfectious pulmonary complications after solid-organ transplantation, addressing epidemiology, risk factors, diagnostic workup, and management. RECENT FINDINGS: Infectious and noninfectious postoperative pulmonary complications depend on the grafted organ and the anatomical site of transplantation. Kidney transplants have the lowest incidence of pulmonary complications, the highest being reported for heart, lung, and liver recipients. Respiratory tract infections, ranking first in heart and lung transplants and second in liver recipients, are a common cause of mortality. Risk factors include end-stage organ disease, comorbidities, perioperative procedures, and graft function. Factors specific for infections are timeline, state of immunosuppression, and graft dysfunction. Nosocomial multi-drug resistant pathogens are frequently responsible for the most severe infections. Aggressive diagnostic workup, early and broad empiric antiinfective therapy, and deescalation policy are the mainstays of their management. The role of intraoperative protective ventilation is under scrutiny. SUMMARY: Pulmonary complications after solid-organ transplantation, and particularly infections, are able to compromise the extremely good results of the transplant procedures. Solid-organ transplantation recipients challenge the ICU physician with unique aspects of their post-transplant course, adding, in an already critical patient, the immunosuppressed state and the quality of the functional recovery of the graft.


Assuntos
Pneumopatias/etiologia , Transplante de Órgãos , Complicações Pós-Operatórias , Humanos
10.
World J Crit Care Med ; 13(2): 92751, 2024 Jun 09.
Artigo em Inglês | MEDLINE | ID: mdl-38855273

RESUMO

Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.

11.
Crit Care ; 17(4): R166, 2013 Jul 26.
Artigo em Inglês | MEDLINE | ID: mdl-23890518

RESUMO

INTRODUCTION: Hydroxyethyl starch (HES) is a commonly used colloid in critically ill patients. However, its safety has been questioned in recent studies and meta-analyses. METHODS: We re-evaluated prospective randomised controlled trials (RCT) from four meta-analyses published in 2013 that compared the effect of HES with crystalloids in critically ill patients, focusing on the adherence to 'presumably correct indication'. Regarding the definition of 'presumably correct indication', studies were checked for the following six criteria (maximum six points): short time interval from shock to randomisation (<6 h), restricted use for initial volume resuscitation, use of any consistent algorithm for haemodynamic stabilisation, reproducible indicators of hypovolaemia, maximum dose of HES, and exclusion of patients with pre-existing renal failure or renal replacement therapy. RESULTS: Duration of fluid administration ranged from 90 min up to a maximum of 90 days. Four studies considered follow-up until 90-day mortality, three studies 28-/30-day mortality, whereas four studies reported only early mortality. Included studies showed a large heterogeneity of the indication score ranging between 1 and 4 points with a median (25%; 75% quartile) of 4 (2; 4). CONCLUSIONS: The most important question, whether or not HES may be harmful when it is limited to immediate haemodynamic stabilisation, cannot be answered yet in the absence of any study sufficiently addressing this question. In order to overcome the limitations of most of the previous studies, we now suggest an algorithm emphasising the strict indication of HES. Additionally, we give a list of suggestions that should be adequately considered in any prospective RCT in the field of acute volume resuscitation in critically ill patients.


Assuntos
Estado Terminal/terapia , Derivados de Hidroxietil Amido/administração & dosagem , Derivados de Hidroxietil Amido/efeitos adversos , Segurança do Paciente/normas , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Hemodinâmica/efeitos dos fármacos , Hemodinâmica/fisiologia , Humanos , Metanálise como Assunto , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como Assunto/mortalidade , Estatística como Assunto/métodos , Fatores de Tempo
12.
Anesthesiol Clin ; 41(3): 595-611, 2023 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-37516497

RESUMO

Pioneered by Thomas Starzl in the early 1970s, liver transplant (LT) is nowadays often considered a final intervention and standard of care to cure many forms of acute and chronic end-stage liver diseases. Started in recipients younger than 60 years old, LT indications are now much broader, and at least, one-fifth of the candidates are older than 65 years. Problems associated with ageing and frailty in LT recipients and their impact on the entire perioperative course are discussed according to a modern anesthesiological perspective and the anesthesiologist covering the role of the perioperative (transplant) physician.


Assuntos
Transplante de Fígado , Humanos , Idoso , Pessoa de Meia-Idade , Envelhecimento , Fatores de Risco
13.
Minerva Anestesiol ; 88(4): 248-258, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-34709014

RESUMO

BACKGROUND: Acute kidney injury (AKI) represents a frequent complication after orthotopic liver transplantation (OLT). This study aimed to evaluate early postoperative AKI incidence during the first 72 h after OLT, perioperative risk factors, and AKI impact on survival. METHODS: From January 2011 to December 2013, 1681 patients underwent OLT in 19 centers and were enrolled in this prospective cohort study. RESULTS: According to RIFLE criteria, AKI occurred in 367 patients, 21.8% (R: 5.8%, I: 6.4%, F: 4.8%, L: 4.8%). Based on multivariate analysis, intraoperative risk factors for AKI were: administration of 5-10 RBCs (OR 1.8, 95% CI 1.3-2.7), dopamine use (OR 1.6, 95% CI 1.2-2.3), post-reperfusion syndrome (OR 1.5, 95% CI 1.0-2.3), surgical complications (OR 2.0, 95% CI 1.3-3.0), and cardiological complications (OR 2.2, 95% CI 1.2-4.0). Postoperative risk factors were: norepinephrine (OR 1.4, 95% CI 1.0-2.0), furosemide (OR 4.2, 95% CI 3.0-5.9), more than 10 RBCs transfusion, (OR 3.7, 95% CI 1.4-10.5), platelets administration (OR 1.6, 95% CI 1.1-2.4), fibrinogen administration (OR 3.0, 95% CI, 1.5-6.2), hepatic complications (OR 4.6, 95% CI 2.9-7.5), neurological complications (OR 2.4, 95% CI 1.5-3.7), and infectious complications (OR 2.7, 95% CI 1.8-4.3). NO-AKI patients' 5-year survival rate was higher than AKI patients (68.06, 95% CI 62.7-72.7 and 81.2, 95% CI 78.9-83.3, P<0.001). CONCLUSIONS: AKI still remains an important risk factor for morbidity and mortality after OLT. Further research to develop new strategies aimed at preventing or minimizing post-OLT AKI is needed.


Assuntos
Injúria Renal Aguda , Transplante de Fígado , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Injúria Renal Aguda/terapia , Humanos , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco
14.
Best Pract Res Clin Anaesthesiol ; 34(1): 51-68, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32334787

RESUMO

New and extended indications, older age, higher cardiovascular risk, and the long-standing cirrhosis-associated complications mandate specific skills for an appropriate preoperative assessment of the liver transplant (LT) candidate. The incidence of cardiac diseases (dysrhythmias, cardiomyopathies, coronary artery disease, valvular heart disease) are increasing among LT recipients: however, no consensus exists among clinical practice guidelines for cardiovascular screening and risk stratification. In spite of different "transplant center-centered protocols", basic "pillars" are common (electrocardiography, baseline echocardiography, functional assessment). Owing to intrinsic limitations, yields and relevance of noninvasive stress tests, under constant scrutiny even if used, are discussed, focusing the definition of the "high risk" candidate and exploring noninvasive imaging and new forms of stress imaging. The aim is to find an appropriate and rational stepwise algorithm. The final commitment is to select the right candidate for a finite resource, the graft, able to save (and change) lives.


Assuntos
Testes de Função Cardíaca , Transplante de Fígado/métodos , Período Pré-Operatório , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/cirurgia
15.
Crit Care Med ; 37(12): 3041-6, 2009 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19770749

RESUMO

OBJECTIVE: To investigate red blood cell rheology in a large intensive care unit population on admission, and to assess the possible influence of comorbidities on the rheology. DESIGN: : Prospective study. SETTING: Medico-surgical intensive care unit with 31 beds. SUBJECTS: All intensive care unit admissions during a 5-month period and 20 healthy volunteers. INTERVENTIONS: Blood sampling. MEASUREMENTS AND MAIN RESULTS: A total of 196 intensive care patients (160 without and 36 with sepsis) and 20 healthy volunteers were studied. Red blood cell rheology (deformability and aggregation) was assessed ex vivo using the laser-assisted optical rotational cell analyzer (LORCA; Mechatronics Instruments BV, AN Zwaag, Netherlands) within the first 24 hrs after intensive care unit admission. Red blood cell deformability was determined by the elongation index in relation to the shear stress (0.3 to 50 Pa) applied on the red blood cell membrane surface. Aggregation was assessed by the aggregation index. Septic patients were more likely to have anemia, coagulation abnormalities, and comorbidities than were nonseptic patients. Red blood cell deformability was significantly altered in septic compared to nonseptic patients and volunteers for the majority of shear stress rates studied. The aggregation index was greater in septic patients than in volunteers (67.9% [54.7-73.5] vs. 61.8% [58.2-68.4]; p < .05). Only sepsis and hematologic disease influenced the elongation index (both p < .01). Other comorbidities, like cancer, diabetes mellitus, cirrhosis, and terminal renal failure, had no effect on the elongation index. Aggregation index was related to the degree of organ failure (Sequential Organ Failure Assessment score), the red blood cell count, and fibrinogen concentrations. CONCLUSIONS: Early alterations of red blood cell rheology are common in intensive care unit patients, especially in those with sepsis. Comorbidities (other than hematologic diseases) do not significantly influence these abnormalities. These alterations could contribute to the microcirculatory alterations observed in critically ill patients.


Assuntos
Deformação Eritrocítica , Sepse/sangue , Adulto , Idoso , Estado Terminal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Tempo
16.
Minerva Anestesiol ; 85(6): 635-664, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30762323

RESUMO

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.


Assuntos
Transtornos da Coagulação Sanguínea/terapia , Transfusão de Sangue/normas , Técnicas Hemostáticas/normas , Assistência Perioperatória/normas , Humanos
17.
Minerva Anestesiol ; 85(12): 1315-1333, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31213042

RESUMO

Perioperative hemodynamic management, through monitoring and intervention on physiological parameters to improve cardiac output and oxygen delivery (goal-directed therapy, GDT), may improve outcome. However, an Italian survey has revealed that hemodynamic protocols are applied by only 29.1% of anesthesiologists. Aim of this paper is to provide clinical guidelines for a rationale use of perioperative hemodynamic management in non cardiac surgical adult patients, oriented for Italy and updated with most recent studies. Guidelines were elaborated according to NICE (National Institute for Health and Care Excellence) and GRADE system (Grading of Recommendations of Assessment Development and Evaluations). Key questions were formulated according to PICO system (Population, Intervention, Comparators, Outcome). Guidelines and systematic reviews were identified on main research databases and strategy was updated to June 2018. There is not enough good quality evidence to support the adoption of a GDT protocol in order to reduce mortality, although it may be useful in high risk patients. Perioperative GDT protocol to guide fluid therapy is recommended to reduce morbidity. Continuous monitoring of arterial pressure may help to identify short periods of hemodynamic instability and hypotension. Fluid strategy should aim to a near zero balance in normovolemic patients at the beginning of surgery, and a slight positive fluid balance may be allowed to protect renal function. Drugs such as inotropes, vasocostrictors, and vasodilatator should be used only when fluids alone are not sufficient to optimize hemodynamics. Perioperative GDT protocols are associated with a reduction in costs, although no economic study has been performed in Italy.


Assuntos
Hemodinâmica , Assistência Perioperatória/normas , Procedimentos Cirúrgicos Operatórios , Humanos , Itália , Assistência Perioperatória/métodos , Guias de Prática Clínica como Assunto
18.
Liver Transpl ; 14(7): 999-1006, 2008 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-18581461

RESUMO

The role of split-liver transplantation (SLT) for two adult recipients is still a matter of debate, and no agreement exists on indications, surgical techniques, and results. The aim of this study was to retrospectively analyze the outcome of our series of SLT. From May 1999 to December 2006, 16 patients underwent SLT at our unit. We used 9 full right grafts (segments 5-8) and 7 full left grafts (segments 1-4). The splitting procedure was always carried out in situ with a fully perfused liver. Postoperative complications were recorded in 8 (50%) patients: 5 (55%) in full right grafts and 3 (43%) in full left grafts. No one was retransplanted. After a median follow-up of 55.82 months (range, 0.4-91.2), 5 (31%) patients died, and the 1-, 3-, and 5-year overall survival rate for patients and grafts was 69%. We considered as a control group for the global outcome 232 whole liver transplantations performed at our unit in the same period of time. Postoperative complications were recorded in 53 (23%) patients, and after a median follow-up of 57.37 months (mean, 55.11; range, 1-102.83), the 1-, 3-, and 5-year overall patient survival was 87%, 82%, and 80%, respectively. In conclusion, SLT for two adult recipients is a technically demanding procedure that requires complex logistics and surgical teams experienced in both liver resection and transplantation. Although the reported rate of survival might be adequate for such a procedure, more efforts have to be made to improve the short-term outcome, which is inadequate in our opinion. The true feasibility of SLT for two adults has to be considered as still under investigation.


Assuntos
Transplante de Fígado/métodos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Transplantes/provisão & distribuição , Resultado do Tratamento
20.
Cell Transplant ; 27(5): 840-846, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29871516

RESUMO

Islet transplantation has been reported to restore normoglycemia and the overall metabolic control in type 1 diabetes mellitus (DM). In the most experienced centers, islet transplantation clinical outcome is similar to that of the whole pancreas transplantation. Long-term islet transplantation function remains a very interesting matter worth discussing. A progressive islet function decrease was reported, probably due to islet exhaustion. In 5 islet-transplanted patients with at least 3-yr follow-up and still insulin independent, their glycemic control was characterized by a blinded retrospective continuous glucose monitoring system (CGMS). Islet transplantation restored glycemic control and glucose variability. Data were compared with patients in the waiting list. All the parameters of glycemic variability tested had improved significantly in patients who had islet transplantation compared with those patients who were on the waiting list. In conclusion, islet transplantation is able to maintain a proper glucose control and normalize glycemic variability in selected patients. A blinded retrospective CGMS is a useful method to characterize glucose homeostasis deeply in vivo in islet-transplanted patients.


Assuntos
Glicemia/metabolismo , Transplante das Ilhotas Pancreáticas , Adulto , Automonitorização da Glicemia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
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