Significant Hyperfibrinolysis in a Patient With Intracardiac Thrombosis: To Give Antifibrinolytics or Not?

The hemostatic system is a delicate balance between the coagulation, anticoagulation, and fibrinolytic systems and is responsible for preventing both hemorrhage and thrombosis. End stage liver disease is characterized by a rebalanced hemostatic system that is fragile and easily tipped towards either hemorrhage or thrombosis. During an orthotopic liver transplantation, patients are exposed to a wide variety of factors that can shift them from a hypercoagulable state to a hypocoagulable state almost instantaneously. The treatment for these two disease states contradict each other, and therefore patients in this condition can be extremely difficult to manage. Here, we present a patient who underwent an orthotopic liver transplantation and suffered an intracardiac thrombosis shortly after reperfusion of the donor graft, that resolved with supportive care, who then went on to develop severe persistent hyperfibrinolysis and massive hemorrhage that was successfully treated with an antifibrinolytic agent.

Iatrogenic Bladder Perforation During Laparoscopy: Revisiting the "Catheter Bag" Sign: A Case Report.

We report a case of an iatrogenic bladder perforation sustained during laparoscopic lysis of adhesions performed for small bowel obstruction. The only sign, discovered by the anesthesiology team, was an inflated urinary catheter collection bag. This case revalidates the "catheter bag" sign and advocates for the placement of an indwelling transurethral urinary catheter before surgical incision in high-risk patients with previous pelvic and/or bladder pathology. In addition, vigilance from anesthesia providers and commitment to communication between anesthesia, surgical, and nursing care teams is emphasized to quickly discover complications and treat accordingly.

Intermittent Boluses of Local Anesthetic Through Quadratus Lumborum Catheters for Analgesia in a Living Donor Hepatectomy.

The demand for liver transplants in the United States far exceeds the supply of organs. As need has increased, so has use of living donors. Coagulopathy and various side effects often preclude the use of neuraxial regional techniques and opioids for postoperative analgesia in patients with large "J" incisions. Here, we present a 25-year-old male undergoing a living donor hepatectomy who received quadratus lumborum catheters placed percutaneously after closure of incision and prior to emergence to provide excellent analgesia and a viable opioid-sparing approach. Quadratus lumborum catheters are a safe option for a multimodal, opioid-sparing approach to analgesia.

Effect of Iboga alkaloids on µ-opioid receptor-coupled G protein activation.

OBJECTIVE: The iboga alkaloids are a class of small molecules defined structurally on the basis of a common ibogamine skeleton, some of which modify opioid withdrawal and drug self-administration in humans and preclinical models. These compounds may represent an innovative approach to neurobiological investigation and development of addiction pharmacotherapy. In particular, the use of the prototypic iboga alkaloid ibogaine for opioid detoxification in humans raises the question of whether its effect is mediated by an opioid agonist action, or if it represents alternative and possibly novel mechanism of action. The aim of this study was to independently replicate and extend evidence regarding the activation of µ-opioid receptor (MOR)-related G proteins by iboga alkaloids. METHODS: Ibogaine, its major metabolite noribogaine, and 18-methoxycoronaridine (18-MC), a synthetic congener, were evaluated by agonist-stimulated guanosine-5´-O-(γ-thio)-triphosphate ([(35)S]GTPγS) binding in cells overexpressing the recombinant MOR, in rat thalamic membranes, and autoradiography in rat brain slices. RESULTS AND SIGNIFICANCE: In rat thalamic membranes ibogaine, noribogaine and 18-MC were MOR antagonists with functional Ke values ranging from 3 uM (ibogaine) to 13 uM (noribogaine and 18MC). Noribogaine and 18-MC did not stimulate [(35)S]GTPγS binding in Chinese hamster ovary cells expressing human or rat MORs, and had only limited partial agonist effects in human embryonic kidney cells expressing mouse MORs. Ibogaine did not did not stimulate [(35)S]GTPγS binding in any MOR expressing cells. Noribogaine did not stimulate [(35)S]GTPγS binding in brain slices using autoradiography. An MOR agonist action does not appear to account for the effect of these iboga alkaloids on opioid withdrawal. Taken together with existing evidence that their mechanism of action also differs from that of other non-opioids with clinical effects on opioid tolerance and withdrawal, these findings suggest a novel mechanism of action, and further justify the search for alternative targets of iboga alkaloids.