Coagulation Alterations in Major Burn Patients: A Narrative Review.

Major burn patients (MBP) can present multifactorial coagulation alterations induced by trauma and endothelial damage, fluid replacement therapy, hypothermia, hypoperfusion, acidosis, and activation of the inflammatory cascade. However, the multiple coagulation alterations that occur are still poorly defined. The aim of this review is to combine the results of the different coagulation tests currently used to study coagulation changes in these patients. The PubMed database was searched for articles reporting factor levels or coagulation tests using the keywords "Burns" and "Blood Coagulation". Of the 720 articles retrieved from the search, 20 were finally included in the review. Coagulopathy in the MBP differs from that of the trauma patient, insofar as the former present with an increase in factors VIII, IX, and vW on admission accompanied by an increase in fibrin and thrombin production. This is followed by activation of fibrinolysis and prolonged prothrombin (PT) and thromboplastin (aPTT) times in the first 24 hours, increased fibrinogen after 48 hours, and thrombocytosis between the second and third week. Viscoelastic testing shows a pattern that shifts from normal coagulation to a hypercoagulable state with no evidence of hyperfibrinolysis. Alterations in PT and aPTT together with elevated Factor VIII have been associated with mortality, while normalization of antithrombin, and protein C and S levels are associated with a good prognosis. Although standard coagulation tests initially show alterations, the MBP does not appear to be hypocoagulable, and viscoelastic testing shows a trend toward hypercoagulability over time. Coagulation disorders affect prognosis in the MBP.

Perioperative Management for the First Uterine Transplant in Southern Europe: A Case Report.

BACKGROUND: The aim of this study was to describe perioperative management concerning the living donor uterine transplantation program at the Hospital Clinic (Barcelona, Spain), in the first successful procedure in Southern Europe. METHODS: Before the date of surgery, both the donor and the recipient are evaluated in the outpatient clinic to detect any possible comorbidities that might complicate or altogether disallow the procedure. In the donor, with a robotically performed surgery, complications regarding cerebral and upper airway edema, as well as reduced access to the patient once docking occurs, are of utmost importance. An aggressive antithrombotic regimen must be in place that includes heparin administered both to the donor and the recipient and aspirin to the recipient. Different strategies to reduce ischemia-reperfusion injury have been studied, with reduced ischemia times currently being the most effective. RESULTS: After surgery, both donor and recipient were taken to the intensive care unit overnight, transferred to the conventional ward the following day and discharged from the hospital within the week. The recipient had her first menstrual period 47 days after the surgery. CONCLUSIONS: The description of challenges regarding perioperative care of women who undergo uterine transplant programs and the rationale in anesthetic management may help other teams implant this program as a solution for a disease that profoundly impairs quality of life.

Comparison between epidural technique and mid-axillary ultrasound-guided TAP block for postoperative analgesia of laparoscopic radical prostatectomy: a quasi-randomized clinical trial.

BACKGROUND: Our goal was to evaluate whether TAP block offers the same analgesic pain control compared to epidural technique in laparoscopic radical prostatectomy surgery through the morphine consumption in the first 48 hours. METHODS: In this study, 45 patients were recruited and assigned to either TAP or epidural. The main study outcome was morphine consumption during the first 48 hours after surgery. Other data recorded were pain at rest and upon movement, technique-related complications and adverse effects, surgical and postoperative complications, length of surgery, need for rescue analgesia, postoperative nausea and vomiting, start of intake, sitting and perambulation, first flatus, and length of in-hospital stay. RESULTS: From a total of 45 patients, two were excluded due to reconversion to open surgery (TAP group = 20; epidural group = 23). There were no differences in morphine consumption (0.96 vs. 0.8 mg; p = 0.78); mean postoperative VAS pain scores at rest (0.7 vs. 0.5; p = 0.72); or upon movement (1.6 vs. 1.6; p = 0.32); in the TAP vs. epidural group, respectively. Sitting and perambulation began sooner in TAP group (19 vs. 22 hours, p = 0.03; 23 vs. 32 hours, p = 0.01; respectively). The epidural group had more technique-related adverse effects. CONCLUSION: TAP blocks provide the same analgesic quality with optimal pain control than epidural technique, with less adverse effects.

Somatostatin Therapy Improves Stellate Cell Activation and Early Fibrogenesis in a Preclinical Model of Extended Major Hepatectomy.

Liver resection treats primary and secondary liver tumors, though clinical applicability is limited by the remnant liver mass and quality. Herein, major hepatic resections were performed in pigs to define changes associated with sufficient and insufficient remnants and improve liver-specific outcomes with somatostatin therapy. Three experimental groups were performed: 75% hepatectomy (75H), 90% hepatectomy (90H), and 90% hepatectomy + somatostatin (90H + SST). Animals were followed for 24 h (N = 6) and 5 d (N = 6). After hepatectomy, portal pressure gradient was higher in 90H versus 75H and 90H + SST (8 (3-13) mmHg vs. 4 (2-6) mmHg and 4 (2-6) mmHg, respectively, p < 0.001). After 24 h, changes were observed in 90H associated with stellate cell activation and collapse of sinusoidal lumen. Collagen chain type 1 alpha 1 mRNA expression was higher, extracellular matrix width less, and percentage of collagen-staining areas greater at 24 h in 90H versus 75H and 90H + SST. After 5 d, remnant liver mass was higher in 75H and 90H + SST versus 90H, and Ki-67 immunostaining was higher in 90H + SST versus 75H and 90H. As well, more TUNEL-staining cells were observed in 90H versus 75H and 90H + SST at 5 d. Perioperative somatostatin modified portal pressure, injury, apoptosis, and stellate cell activation, stemming changes related to hepatic fibrogenesis seen in liver remnants not receiving treatment.

Perioperative considerations for kidney and pancreas-kidney transplantation.

Kidney transplantation is the treatment of choice in patients with end-stage renal disease, as it improves survival and quality of life. Living donor kidney transplant prior to pancreas transplantation, or simultaneous pancreas and kidney transplantation are discussed. Patients usually present comorbidities and extensive preoperative workups are recommended, especially cardiac assessment, though type and frequency of surveillance is not established. Nephroprotective strategies include adequate fluid status and goal-directed therapy. The conventional use of diuretics has not demonstrated a real nephroprotective effect at follow-up. Thromboprophylaxis regimes, especially for the pancreatic graft outcome, are of importance. Notably, transplantation in the obese population has increased in recent decades. Strict preoperative evaluation and pulmonary considerations must be kept in mind. Finally, robotic kidney transplant is a recent approach that presents anesthetic challenges, mainly related to steep Trendelenburg position and fluid restriction.

Heparin but not tissue plasminogen activator improves outcomes in donation after circulatory death liver transplantation in a porcine model.

Ischemic-type biliary lesions (ITBLs) arise most frequently after donation after circulatory death (DCD) liver transplantation and result in high morbidity and graft loss. Many DCD grafts are discarded out of fear for this complication. In theory, microvascular thrombi deposited during donor warm ischemia might be implicated in ITBL pathogenesis. Herein, we aim to evaluate the effects of the administration of either heparin or the fibrinolytic drug tissue plasminogen activator (TPA) as means to improve DCD liver graft quality and potentially avoid ITBL. Donor pigs were subjected to 1 hour of cardiac arrest (CA) and divided among 3 groups: no pre-arrest heparinization nor TPA during postmortem regional perfusion; no pre-arrest heparinization but TPA given during regional perfusion; and pre-arrest heparinization but no TPA during regional perfusion. In liver tissue sampled 1 hour after CA, fibrin deposition was not detected, even when heparin was not given prior to arrest. Although it was not useful to prevent microvascular clot formation, pre-arrest heparin did offer cytoprotective effects during CA and beyond, reflected in improved flows during regional perfusion and better biochemical, functional, and histological parameters during posttransplantation follow-up. In conclusion, this study demonstrates the lack of impact of TPA use in porcine DCD liver transplantation and adds to the controversy over whether the use of TPA in human DCD liver transplantation really offers any protective effect. On the other hand, when it is administered prior to CA, heparin does offer anti-inflammatory and other cytoprotective effects that help improve DCD liver graft quality. Liver Transplantation 24 665-676 2018 AASLD.

Colorectal carcinoma in the frail surgical patient. Implementation of a Work Area focused on the Complex Surgical Patient improves postoperative outcome. / Resultados de morbimortalidad en cáncer colorrectal en paciente quirúrgico frágil. Implementación de un Área de Atención al Paciente Quirúrgico Complejo.

INTRODUCTION: Advanced age and comorbidity impact on post-operative morbi-mortality in the frail surgical patient. The aim of this study is to assess the impact of a comprehensive, multidisciplinary and individualized care delivered to the frail patient by implementation of a Work Area focused on the Complex Surgical Patient (CSPA). METHODS: Retrospective study with prospective data collection. Ninety one consecutive patients, classified as frail (ASAIII or IV, Barthel<80 and/or Pfeiffer>3) underwent curative radical surgery for colorectal carcinoma between 2013 and 2015. GroupI: 35 patients optimized by the CSPA during 2015. GroupII: 56 No-CSPA patients, treated prior to CSPA implementation, during 2014-2015. Group homogeneity, complication rate, length of stay, reoperations, readmissions, costs and overall mortality were analyzed and adjusted by Diagnosis-Related Group (DRG). RESULTS: There were no statistically significant differences in term of age, gender, ASA classification, body mass index, tumor staging and type of surgical intervention between the two groups. Major complications (Clavien-DindoIII-IV) (12.5% vs. 28.5%, P=.04), hospital stay (12.6±6days vs. 15.2±6days, P=0.041), readmissions (12.5% vs. 28.3%, P<0.041), and patient episode cost weighted according to DRG (3.29±1 vs. 4.3±1, P=0.008) were statistically inferior in Group CSPA. There were no differrences in reoperations (6.2% vs. 5.3%) or mortality (6.2% vs. 7.1%). 96.9% of patients of GroupI manifested having received a satisfactory attention and quality of life. CONCLUSIONS: Implementation of a CSPA, delivering surgical care to frail colorectal cancer patients, involves a reduction of complications, length of stay and readmissions, and is a cost-effective arrangement.

Pretreatment with endothelium-derived nitric oxide synthesis modulators on gastrointestinal microcirculation during NOTES: an experimental study.

BACKGROUND AND STUDY AIMS: On-demand endoscopic insufflation during natural orifice transluminal endoscopic surgery (NOTES) adversely affects microcirculatory blood flow (MBF), even with low mean intra-abdominal pressure, suggesting that shear stress caused by time-varying flow fluctuations has a great impact on microcirculation. As shear stress is inversely related to vascular diameter, nitric oxide (NO) production acts as a brake to vasoconstriction. OBJECTIVE: To assess whether pretreatment by NO synthesis modulators protects gastrointestinal MBF during transgastric peritoneoscopy. METHODS: Fourteen pigs submitted to cholecystectomy by endoscope CO2 insufflation for 60 min were randomized into 2 groups: (1) 150 mg/kg of N-acetyl cysteine (NAC, n = 7) and (2) 4 ml/kg of hypertonic saline 7.5 % (HS, n = 7), and compared to a non-treated NOTES group (n = 7). Five animals made up a sham group. Colored microspheres were used to assess changes in MBF. RESULTS: The average level of intra-abdominal pressure was similar in all groups (9 mmHg). In NOTES group microcirculation decrease compared with baseline was greater in renal cortex, mesocolon, and mesentery (41, 42, 44 %, respectively, p < 0.01) than in renal medulla, colon, and small bowel (29, 32, 34, respectively, p < 0.05). NAC avoided the peritoneoscopy effect on renal medulla and cortex (4 and 14 % decrease, respectively) and reduced the impact on colon and small bowel (20 % decrease). HS eliminated MBF changes in colon and small bowel (14 % decrease) and modulated MBF in renal medulla and cortex (19 % decrease). Neither treatment influenced mesentery MBF decrease. CONCLUSIONS: Both pretreatments can effectively attenuate peritoneoscopy-induced deleterious effects on gastrointestinal MBF.

Cardiomiopatia severa secundaria a feocromocitoma: utilidad del sulfato de magnesio. Reporte de un caso / Severe cardiomyopathy secondary to pheochromocytoma: Usefulness of magnesium sulfate. Case report

The following report on the perioperative anesthetic management of severe cardiomyopathy and resection of pheochromocytoma tumors offers a clinical and pharmaceutical experience with a good outcome for a high-risk pathology with little available world literature. The female patient accesses emergency services in distress with tachycardia, labile blood pressure, dyspnea, and severe abdominal pain. Clinical studies reveal heart failure, an adrenal mass, and derivates of high levels of catecholamines in the blood, which leads to the diagnosis of severe cardiomyopathy induced by pheochromocytoma. The medical management for the acute crisis is performed with therapy in the intensive care unit, antihypertensives and magnesium sulfate. Once stabilized, a laparoscopic tumor resection followed. Her postoperative progress was adequate with a progressive resolution of symptoms. Cardiomyopathy secondary to pheochromocytoma is a pathology with high morbimortality and low frequency and is produced by the action of great quantities of catecholamines released subacutely due to hemorrhagic tumor necrosis or manipulation of the pheochromocytoma. It requires strict care in its acute crises and during surgery for its definitive resection. This report shows our experience with the usefulness of magnesium sulfate as a contributory drug in the control of this pathology throughout the perioperative period due to its mechanism of action and pharmacodynamics. Its easy availability in hospitals, the good clinical results it produces, and its scientific backing are important factors that make it a pharmacological option for pheochromocytoma.

El siguiente reporte de manejo anestésico perioperatorio de cardiomiopatía severa y resección de tumor de feocromocitoma, ofrece una experiencia clínica y farmacológica con buen resultado, de una patología de alto riesgo con poca literatura mundial. La paciente ingresa al servicio de urgencias con angustia, taquicardia, tensión arterial lábil, disnea y dolor abdominal severos. Sus estudios clínicos revelan insuficiencia cardiaca, masa suprarenal y derivados de catecolaminas elevados en sangre, que hacen diagnóstico de cardiomiopatía severa inducida por Feocromocitoma; se realiza el manejo médico de la crisis aguda con terapia en unidad de cuidado intensivo, antihipertensivos y sulfato de magnesio y una vez estabilizada se lleva a resección tumoral laparoscopica. Su evolución postoperatoria fue adecuada, con resolución progresiva de los síntomas. La cardiomiopatía secundaria a feocromocitoma es una patología de alta morbimortalidad e inusual frecuencia, producida por la acción de grandes cantidades de catecolaminas liberadas de modo subagudo por necrosis tumoral hemorrágica o manipulación de feocromocitoma, que requiere manejo estricto en su crisis aguda y en la cirugía de resección definitiva. Este reporte muestra la experiencia de la utilidad del sulfato de magnesio, como fármaco coadyuvante en el control de esta patología durante todo el periodo perioperatorio, por su mecanismo de acción y farmacodinamia. Su fácil accesibilidad hospitalaria, buen resultado clínico y soporte científico son factores importantes para ser considerado una opción farmacológica en Feocromocitoma.

Effect of transgastric natural orifice transluminal endoscopic surgery peritoneoscopy on abdominal organ microcirculation: an experimental controlled study.

BACKGROUND AND AIMS: On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal pressure. Its effects on splanchnic microcirculation may differ from those of steady intra-abdominal pressure, because pressure characteristics affect crucial intravascular hemodynamic forces--pressure and shear--adapting flow to local metabolic needs. Our aim was to assess the effect of natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy on splanchnic microcirculatory blood flow. METHODS: Twenty-one swine were randomized to the following: cholecystectomy by transgastric NOTES (n = 8), cholecystectomy by standard laparoscopy (Lap) (n = 8), and a sham group (n = 5). During NOTES, CO2 was manually insufflated with a maximum allowed pressure of 30 mm Hg. In the Lap group, intra-abdominal pressure was maintained at 14 mm Hg. Systemic hemodynamics were measured, and microcirculatory blood flow was quantified by using colored microspheres. RESULTS: Mean intra-abdominal pressure was lower in NOTES than in the Lap group (P = .038). In both groups, cardiac index and preload remained unchanged, whereas systemic vascular resistances increased over time, with a lesser increase in the Lap group (2-way analysis of variance; P = .041). In pneumoperitoneum groups, microcirculatory blood flow decreased similarly in the renal medulla, stomach, small bowel, colon, and mesocolon by 30%, 45%, 34%, 32%, and 37%, respectively. In NOTES, there was a greater microcirculatory blood flow decrease in the renal cortex (NOTES 41% vs Lap 35%; P = .044) and mesentery (NOTES 44% vs Lap 38%; P = .041). CONCLUSIONS: These findings suggest that both types of pneumoperitoneum have similar physiologic effects on microcirculatory blood flow. However, on-demand pneumoperitoneum (NOTES group) caused a greater microcirculatory blood flow decrease in areas with low metabolic needs, redistributing blood flow toward metabolically active areas.

Step-by-step guide for a simplified model of porcine orthotopic liver transplant.

BACKGROUND: Based on similar anatomy, physiology, and size to humans, pigs provide an excellent means for studying new therapies related to orthotopic liver transplant (OLT). Techniques that have been described to date, however, are unnecessarily complex and increase the likelihood of morbidity and adverse outcome. MATERIALS AND METHODS: Male outbred weanling pigs underwent OLT according to our procedure, with a short anhepatic time (<20 min) and without veno-venous bypass or vasoactive substances during the anhepatic phase. Vascular anastomoses were performed identical to the clinical setting, and a simple stented choledochocholedochostomy was created. RESULTS: The authors have performed this procedure 130 times using four transplant models: standard, whole-liver (n = 10), small-for-size (n = 48), donor after cardiac death (n = 44), and donor adenoviral gene transfection (n = 28). The average cold ischemic and anhepatic times were 302 ± 43 and 17 ± 3 min, respectively. Hypotension was successfully treated with intravenous fluids. In all cases, the recipient survived the operation and was extubated. Survival to the end follow-up varied according to the model and was 56% (73/130) for all cases. At autopsy or euthanasia, no vascular thrombosis or outflow obstruction was found. Survival was 100% for pigs transplanted with standard, whole-liver grafts (n = 10). In this group, AST and bilirubin rose during the first 24 h after graft reperfusion, while the Quick prothrombin time (QPT) fell. By the fifth postoperative day, these parameters had returned to baseline. CONCLUSIONS: This model is straightforward and reproducible and offers surgeons and researchers the opportunity to perform OLT studies under clinically relevant conditions.