N-acetylcysteine infusion in preventing hepatotoxicity secondary to intravenous injection of household bleach.

We present a case of non-accidental injection of 40 ml of domestic bleach through a long-term central venous catheter (CVC) with subsequent AKI, and for the first time in the literature severe coagulopathy and acute liver injury. We detail the clinical course of events and our management plan which adds to the body of evidence for prognosis and treatment in these unusual cases.

Postoperative epidural analgesia in obese patients undergoing liver resection surgery.

AIM: To investigate the relation of body mass index (BMI) with postoperative pain scores and volume of local anaesthetic (LA) administered epidurally in patients undergoing liver resection surgery. METHODS: Retrospective data from 167 patients who had epidural analgesia (EA) for liver resection surgery were analysed: 123 with BMI < 30kgm-2 and 44 with BMI > 30kgm-2. RESULTS: Total volume of intraoperative bolus of epidural analgesia (EA) was not different between the BMI more than 30 kgm-2 and BMI less than 30 kgm-2 groups (p less 0.05). Mean rate of infusion (8.2±2.7 ml/h vs. 7.9±1.9 ml/h, p=0.0018), pain scores immediately after extubation of the trachea (0.91±0.9 vs. 0.55±0.7, p=0.017) and that before removal of epidural catheter (0.7±0.55 vs. 0.7±0.95, p=0.015) were higher in the BMI > 30kgm-2 group when compared with the BMI ≤ 30kgm-2 group. However, there was no significant difference between the numbers of segments blocked. CONCLUSION: The patients with BMI more than 30 kgm-2 undergoing liver resection experienced more postoperative pain on the day of surgery and before epidural catheter removal than patients with BMI less than 30 kgm-2, despite a higher rate of epidural infusion. Further studies are necessary to confirm these findings in order to determine adequate local anaesthetic dosing for thoracic epidural analgesia in obese patients.

Emergency subtotal hepatectomy: a new concept for acetaminophen-induced acute liver failure: temporary hepatic support by auxiliary orthotopic liver transplantation enables long-term success.

INTRODUCTION: Acetaminophen (paracetamol) overdose (AOD) has recently emerged as the leading cause of acute liver failure (ALF) in the United States, with an incidence approaching that seen in the United Kingdom. We describe a new way to treat AOD ALF patients fulfilling King's College criteria for "super-urgent" liver transplantation. METHODS: Beginning in June 1998, we have been piloting a clinical program of subtotal hepatectomy and auxiliary orthotopic liver transplantation (ALT) for AOD ALF. Our technique is based on the following principles: (1) subtotal hepatectomy; (2) auxiliary transplantation of a whole liver graft; (3) gradual withdrawal of immunosuppression after recovery. Results were compared with patients who had undergone an orthotopic liver transplantation (OLT) for AOD ALF in the same period. Quality of life comparisons were made using the SF36 questionnaire. RESULTS: Thirteen patients underwent this procedure between June 1998 and March 2005. Median survival is 68 months (range, 0-102 m). Actual survival data show that 9 of 13 patients are alive (69%) compared with 7 of 13 OLT patients (54%). One ALT patient required a retransplantation with an OLT due to hepatic vein thrombosis, and immunosuppression is therefore maintained. The other 8 surviving ALT patients are off immunosuppression. These 8 ALT patients have normal liver function and have a better quality of life compared with the 7 surviving OLT patients. CONCLUSION: Our results with this new technique are encouraging: 69% actual survival, no long-term immunosuppression requirement, and improved quality of life in the 62% successful cases.

A multicenter evaluation of safety of early extubation in liver transplant recipients.

Small single-institutional studies performed prior to the introduction of organ allocation using the Model for End-Stage Liver Disease (MELD) suggest that early airway extubation of liver transplant recipients is a safe practice. We designed a multicenter study to examine adverse events associated with early extubation in patients selected for liver transplantation using MELD score. A total of 7 institutions extubated all patients meeting study criteria and reported adverse events that occurred within 72 hours following surgery. Adverse events were uncommon: occurring in only 7.7% of 391 patients studied. Most adverse events were pulmonary or surgically related. Pulmonary complications were usually minor, requiring only an increase in ambient oxygen concentration. The majority of surgical adverse events required additional surgery. Analysis of a limited set of perioperative variables suggest that blood transfusions and technical factors were associated with an increased risk of adverse events. In conclusion, while early extubation appears to be safe under specified circumstances, there are performance differences between institutions that remain to be explained.

The safety and efficacy of the administration of recombinant activated factor VII in major surgery and trauma patients.

Recombinant activated Factor VII (rFVIIa) has been successfully used in the treatment of haemophilia A and B with associated inhibitors for some years. Activated Factor VII binds to activated platelets independently of tissue factor. The resulting stimulation of an exaggerated early thrombin burst at sites of vascular injury makes it an attractive potential treatment for massive, uncontrolled bleeding associated with surgery and trauma. This article describes the evidence relating to surgery and trauma. The lack of large, controlled trials of rFVIIa means that a definitive recommendation regarding its use cannot be made at present. However, in the context of clearly defined protocols and balanced treatment strategies, rFVIIa may have a role in traumatic bleeding. Large scale, randomised controlled trials in trauma are required, as is further work on the safety profile of rFVIIa with an independent international safety monitoring committee.