A Randomized Controlled Comparison of the Internal Jugular Vein and the Subclavian Vein as Access Sites for Central Venous Catheterization in Pediatric Cardiac Surgery.

OBJECTIVES: To compare internal jugular vein and subclavian vein access for central venous catheterization in terms of success rate and complications. DESIGN: A 1:1 randomized controlled trial. SETTING: Baskent University Medical Center. PATIENTS: Pediatric patients scheduled for cardiac surgery. INTERVENTIONS: Two hundred and eighty children undergoing central venous catheterization were randomly allocated to the internal jugular vein or subclavian vein group during a period of 18 months. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the first-attempt success rate of central venous catheterization through either approach. The secondary outcomes were the rates of infectious and mechanical complications. The central venous catheterization success rate at the first attempt was not significantly different between the subclavian vein (69%) and internal jugular vein (64%) groups (p = 0.448). However, the overall success rate was significantly higher through the subclavian vein (91%) than the internal jugular vein (82%) (p = 0.037). The overall frequency of mechanical complications was not significantly different between the internal jugular vein (25%) and subclavian vein (31%) (p = 0.456). However, the rate of arterial puncture was significantly higher with internal jugular vein (8% vs 2%; p = 0.03) and that of catheter malposition was significantly higher with subclavian vein (17% vs 1%; p < 0.001). The rates per 1,000 catheter days for both positive catheter-tip cultures (26.1% vs 3.6%; p < 0.001) and central-line bloodstream infection (6.9 vs 0; p < 0.001) were significantly higher with internal jugular vein. There were no significant differences between the groups in the length of ICU and hospital stays or in-hospital mortality rates (p > 0.05 for all). CONCLUSIONS: Central venous catheterization through the internal jugular vein and subclavian vein was not significantly different in terms of success at the first attempt. Although the types of mechanical complications were different, the overall rate was similar between internal jugular vein and subclavian vein access. The risk of infectious complications was significantly higher with internal jugular vein access.

Radial mean arterial pressure reliably reflects femoral mean arterial pressure in uncomplicated pediatric cardiac surgery.

OBJECTIVE: To see if radial mean arterial pressure reliably reflects femoral mean arterial pressure in uncomplicated pediatric cardiac surgery. DESIGN: An ethics committee-approved prospective interventional study. SETTING: Operating room of a tertiary care hospital. PARTICIPANTS: Forty-five children aged 3 months to 4 years who underwent pediatric cardiac surgery with hypothermic cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Simultaneous femoral and radial arterial pressures were recorded at 10-minute intervals intraoperatively. A pressure gradient>5mmHg was considered to be clinically significant. The patients' mean age was 14±11 months and and mean weight was 8.0±3.0kg. A total of 1,816 simultaneous measurements of arterial pressure from the radial and femoral arteries were recorded during the pre-cardiopulmonary bypass, cardiopulmonary bypass, and post-cardiopulmonary bypass periods, including 520 (29%) systolic arterial pressures, 520 (29%) diastolic arterial pressures, and 776 (43%) mean arterial pressures. The paired mean arterial pressure measurements across the 3 periods were significantly and strongly correlated, and this was true for systolic arterial pressures and diastolic arterial pressures as well (r>0.93 and p<0.001 for all). Bland-Altman plots demonstrated good agreement between femoral and radial mean arterial pressures during the pre-cardiopulmonary bypass, cardiopulmonary bypass, and post-cardiopulmonary bypass periods. A significant radial-to-femoral pressure gradient was observed in 150 (8%) of the total 1,816 measurements. These gradients occurred most frequently between pairs of systolic arterial pressure measurements (n = 113, 22% of all systolic arterial pressures), followed by mean arterial pressure measurements (n = 28, 4% of all mean arterial pressures) and diastolic arterial pressures measurements (n = 9, 2% of all diastolic arterial pressures). These significant gradients were not sustained (ie, were not recorded at 2 or more successive time points). CONCLUSIONS: The results suggested that radial mean arterial pressure provided an accurate estimate of central mean arterial pressure in uncomplicated pediatric cardiac surgery. There was a significant gradient between radial and femoral mean arterial pressure measurements in only 4% of the mean arterial pressure measurements, and these significant gradients were not sustained.

Percutaneous dilational tracheotomy for airway management in a newborn with Pierre-Robin syndrome and a glossopharyngeal web.

Pierre-Robin syndrome (PRS) is often associated with difficulty in endotracheal intubation. We present the use of percutaneous dilational tracheotomy (PDT) for airway management of a newborn with PRS and a glossopharyngeal web. A 2-day-old term newborn with PRS and severe obstructive dyspnea was evaluated by the anesthesiology team for airway management. A direct laryngoscopy revealed a glossopharyngeal web extending from the base of the tongue to the posterior pharyngeal wall. The infant was spontaneously breathing through a 2 mm diameter fistula in the center of this web. It was decided that endotracheal intubation was impossible, and a PDT was planned. The trachea of the newborn was cannulated, using a 20 gauge peripheral venous catheter and a 0.71 mm guide wire was introduced through this catheter. Using 5 French, 7 French, 9 French, and 11 French central venous catheter kit dilators, staged tracheotomy stoma dilation was performed. By inserting a size 3.0 tracheotomy cannula, PDT was successfully completed in this newborn. This case describes the successful use of PDT for emergency airway management of a newborn with PRS and glossopharyngeal web.

Immediate Tracheal Extubation After Pediatric Liver Transplantation.

OBJECTIVES: We examined whether immediate tracheal extubation among pediatric liver transplant recipients was safe and feasible. MATERIALS AND METHODS: We retrospectively analyzed medical records of pediatric liver transplant recipients at Baskent University Hospital from January 2012 to December 2017. We grouped children who were extubated in the operating room versus those extubated in the intensive care unit. RESULTS: In our study group of 81 pediatric patients, median age was 4 years (range, 4 mo to 16 y) and 44 (54%) were male. Immediate tracheal extubation in the operating room was performed in 39 patients (48%). Children who remained intubated (n = 42) had more frequent massive hemorrhage (14% vs 0%; P = .015), received larger amounts of packed red blood cells (19.3 vs 10.2 mL/kg; P < .001), and had higher serum lactate levels (9.0 vs 6.9 mmol/L; P = .001) intraoperatively. All children with open abdomens postoperatively remained intubated (n = 7). Patients extubated in the operating room received less vasopressors (1 [3%] vs 12 [29%]; P = .002) and antibiotics (11 [28%] vs 22 [52%]; P = 0.041) and developed infections less frequently postoperatively (3.0 [8%] vs 15.0 [36%]; P = .003). Children extubated in the operating room had shorter mean stay in the intensive care unit (2.0 vs 4.5 days; P < .001). Hospital mortality was higher in children who remained intubated (12% vs 0%; P = .026). CONCLUSIONS: Immediate tracheal extubation was well tolerated in almost half of our patients and did not compromise their outcomes. Patients who remained intubated had longer intensive care unit stays and higher hospital mortalities. Therefore, we recommend immediate tracheal extubation in the operating room after pediatric liver transplant among those children without intraoperative requirements for massive blood transfusion, high-dose vasopressors, high serum lactate levels, and open abdomen.

Risk Factors for Postoperative Prolonged Mechanical Ventilation After Pediatric Liver Transplantation.

OBJECTIVES: Duration of postoperative mechanical ventilation after pediatric liver transplant may influence pulmonary functions, and postoperative prolonged mechanical ventilation is associated with higher morbidity and mortality. Here, we determined its incidence and risk factors after pediatric liver transplant at our center. MATERIALS AND METHODS: We retrospectively analyzed the records of 121 children who underwent liver transplant between April 2007 and April 2017 (305 total liver transplant procedures were performed during this period). Prolonged mechanical ventilation was defined as postoperative tracheal extubation after 24 hours. RESULTS: Mean age at transplant was 6.2 ± 5.4 years and 71/121 children (58.7%) were male. Immediate tracheal extubation was achieved in 68 children (56.2%). Postoperative prolonged mechanical ventilation was needed in 12 children (9.9%), with mean extubation time of 78.0 ± 83.4 hours. Reintubation was required in 13.4%. Logistic regression analysis revealed that presence of preoperative hepatic encephalopathy (odds ratio of 0.130; 95% confidence interval, 0.027-0.615; P = .01), high aspartate amino transferase levels (odds ratio of 1.001; 95% confidence interval, 1.000-1.002; P = .02), intraoperative usage of more packed red blood cells (odds ratio of 1.001; 95% confidence interval, 1.000-1.002; P = .04), and longer surgery duration (odds ratio of 0.723; 95% confidence interval, 0.555-0.940, P = .01) were independent risk factors for postoperative prolonged mechanical venti-lation. Although mean length of intensive care unit stay was significantly longer (12.6 ± 13.6 vs 6.0 ± 0.6 days; P = .001), mortality was similar in children with and without postoperative prolonged mechanical ventilation. CONCLUSIONS: Our results indicate that postoperative prolonged mechanical ventilation was needed in 9.9% of our children. Predictors of postoperative prolonged mechanical ventilation after pediatric liver transplant at our center were preoperative presence of hepatic encephalopathy, high aspartate amino transferase levels, intraoperative usage of more packed red blood cells, and longer surgery duration.

Early Postoperative Acute Kidney Injury Among Pediatric Liver Transplant Recipients.

OBJECTIVES: Acute kidney injury after pediatric liver transplant is associated with increased morbidity and mortality. Here, we evaluated children with acute kidney injury early posttransplant using KDIGO criteria to determine incidence, risk factors, and clinical outcomes. MATERIALS AND METHODS: In this retrospective cohort study, medical records of all patients < 16 years old who underwent liver transplant from April 2007 to April 2017 were reviewed. RESULTS: Of 117 study patients, 69 (59%) were male and median age at transplant was 72 months (range, 12-120 mo). Forty children (34.2%) had postoperative acute kidney injury, with most having stage 1 disease (n = 21). Compared with children who had acute kidney injury versus those who did not, preoperative activated partial thromboplastin time (median 35.6 s [interquartile range, 32.4-42.8 s] vs 42.5 s [interquartile range, 35-49 s]; P = .007), intraoperative lactate levels at end of surgery (median 5.3 mmol/L [interquartile range, 3.3-8.6 mmol/L] vs 7.9 mmol/L [interquartile range, 4.3-11.2 mmol/L]; P = .044), and need for open abdomen (3% vs 15%; P= .024) were significantly higher. Logistic regression analysis revealed that preoperative high activated partial thromboplastin time (P= .02), intraoperative lactate levels at end of surgery (P = .02), and need for open abdomen (P = .03) were independent risk factors for acute kidney injury. Children who developed acute kidney injury had significantly longer intensive care unit stay (7.1 ± 8.5 vs 4.4 ± 5.4 days, P= .04) and mortality (12.8% vs 1.8%; P = .01). CONCLUSIONS: Early postoperative acute kidney injury occurred in 34.2% of pediatric liver transplant recipients, with patients having increased mortality risk. High preoperative activated partial throm-boplastin time, high intraoperative end of surgery lactate levels, and need for open abdomen were shown to be associated with acute kidney injury after pediatric liver transplant.

Predictors of Immediate Tracheal Extubation in the Operating Room After Pediatric Liver Transplantation.

OBJECTIVES: Pediatric orthotopic liver transplant recipients frequently need mechanical ventilation during the immediate posttransplant period. However, intensive care unit beds are costly and scarce; therefore, anticipating which patients will require postoperative mechanical ventilation support is important. In addition, immediate postoperative extubation may reduce the incidence of postoperative respiratory complications and improve patient outcomes after orthotopic liver transplant. Here, we aimed to determine the predictors of need for mechanical ventilation after orthotopic liver transplant in pediatric patients. MATERIALS AND METHODS: We retrospectively analyzed the records of 57 pediatric patients who underwent orthotopic liver transplant (performed by the same team at Baskent University Hospital from April 1996 to August 2009). Patients were divided into 2 groups according to whether they required postoperative mechanical ventilation or not. Collected data included demographic features; comorbidities; cause of liver failure; perioperative laboratory values; intraoperative hemodynamic parameters; use and volume of crystalloids, colloids, and blood products; albumin levels; portal vein clamping time, requirement of inotropes/vasopressors; and anesthesia duration. RESULTS: Mean age and body weight of patients were 25.0 ± 23.1 months and 10.8 ± 5.3 kg, respectively. Of 57 patients, 26 (46%) needed postoperative mechanical ventilation. Compared with those who did not require postoperative mechanical ventilation, patients who required mechanical ventilation had growth failure (P = .03), higher mean intraoperative lactate level (P = .03), and higher mean intraoperative fresh frozen plasma/erythrocyte suspension (P = .049) and intraoperative vasopressor (P = .022) requirements. Multivariate logistic regression analysis revealed that growth failure (odds ratio = 37; P = .03) and higher intraoperative lactate level (odds ratio = 1.5; P = .03) were predictors of the need for mechanical ventilation. CONCLUSIONS: About 46% of our pediatric orthotopic liver transplant recipients required mechanical ventilation postoperatively. Growth failure and higher intraoperative lactate levels were associated with need for postoperative mechanical ventilation.

Comparison of measured versus predicted energy requirements in critically ill cancer patients.

BACKGROUND: Accurate determination of caloric requirements is essential to avoid feeding-associated complications in critically ill patients. METHODS: In critically ill cancer patients we compared the measured and estimated resting energy expenditures. All patients admitted to the oncology intensive care unit between March 2004 and July 2005 were considered for inclusion. For those patients enrolled (n = 34) we measured resting energy expenditure via indirect calorimetry, and estimated resting energy expenditure in 2 ways: clinically estimated resting energy expenditure; and the Harris-Benedict basal energy expenditure equation. RESULTS: Clinically estimated resting energy expenditure was associated with underfeeding, appropriate feeding, and overfeeding in approximately 15%, 15%, and 71% of the patients, respectively. The Harris-Benedict basal energy expenditure was associated with underfeeding, appropriate feeding, and overfeeding in approximately 29%, 41%, and 29% of the patients, respectively. The mean measured resting energy expenditure (1,623 +/- 384 kcal/d) was similar to the mean Harris-Benedict basal energy expenditure without the addition of stress or activity factors (1,613 +/- 382 kcal/d, P = .87), and both were significantly lower than the mean clinically estimated resting energy expenditure (1,862 +/- 330 kcal/d, P < or = .003 for both). There was a significant correlation only between mean measured resting energy expenditure and mean Harris-Benedict basal energy expenditure (P < .001), but the correlation coefficient between those values was low (r = 0.587). CONCLUSIONS: Underfeeding and overfeeding were common in our critically ill cancer patients when resting energy expenditure was estimated rather than measured. Indirect calorimetry is the method of choice for determining caloric need in critically ill cancer patients, but if indirect calorimetry is not available or feasible, the Harris-Benedict equation without added stress and activity factors is more accurate than the clinically estimated resting energy expenditure.

Distal Limb Reperfusion During Percutaneous Femoral Arterial Cannulation for Veno-Arterial Extracorporeal Membrane Oxygenation in an Adult Patient.

Ischemia and compartment syndrome may be seen, especially in the distal limb, after femora-femoral cannulation for extracorporeal membrane oxygenation (ECMO). Several techniques have been used to decrease the rate of complications. Arterial hypoxemia may be prevented by reperfusion with distal limb. Prophylactic superficial femoral artery cannulation results in ease in operation and prevents perfusion. In the present case, we present prophylactic superficial femoral artery cannulation for limb reperfusion.

Rituximab Therapy for Rejection in Pediatric Heart Transplant.

OBJECTIVES: Humoral rejection is the B-cell-mediated production of immunoglobulin G antibody against the transplanted heart. Antibody-mediated rejection may be resistant to standard immunosuppressive therapy and is associated with high mortality and graft loss. Rituximab can be used to treat antibody-mediated rejection in heart transplant recipients. This retrospective study describes our experience with rituximab treatment in children with heart transplants. MATERIALS AND METHODS: We present 7 pediatric patients with antibody-mediated rejection who were treated with plasma exchange and rituximab therapy. Rituximab was given at a dose of 375 mg/m2 by slow infusion in the intensive care unit after 5 days of plasmapheresis, in addition to a conventional regimen consisting of steroids, mycophenolate mofetil, and tacrolimus. The peripheral blood count and sodium, potassium, serum urea nitrogen, creatinine, aspartate aminotransferase, and alanine aminotransferase levels were measured in all patients before and after treatment. RESULTS: Seven patients were treated with plasma exchange and rituximab. We repeated this therapy in 5 patients because of refractoriness or recurrent rejection. After diagnoses of antibody-mediated rejection, 4 patients died within 6 months (mortality rate of 57.1%). We did not observe any adverse effects or complications related to rituximab. CONCLUSIONS: Rituximab can be used in humoral rejection after pediatric heart transplant. However, the success of the treatment is controversial, and further study is needed to find an effective treatment for antibody-mediated rejection and steroid-resistant cellular rejection in children.

Perioperative anesthetic management for recipients of orthotopic liver transplant undergoing nontransplant surgery.

OBJECTIVES: The number of organ transplant recipients who present for nontransplant surgery has increased annually. The aim of this study was to evaluate the perioperative anesthetic management of recipients of an orthotopic liver transplant who have undergone nontransplant surgery at Baskent University Hospital. PATIENTS AND METHODS: The medical records of 22 recipients of an orthotopic liver transplant who had undergone a total of 32 nontransplant elective surgeries between December 1988 and February 2006 were retrospectively reviewed. Demographic information, including the anesthetic management and the results of perioperative liver and renal function tests, was recorded. RESULTS: The mean age of the patients at the time of transplant was 20.2 +/- 17.9 years. The mean interval from liver transplant to the first surgery was 739.1 +/- 502.2 days. The most frequent type of surgery was abdominal (28.1%). The types of anesthetic techniques used were general (75%), regional (9.4%), local (9.4%), and sedoanalgesia (6.3%). General anesthesia was induced with thiopental, propofol, or ketamine, and was maintained with isoflurane and nitrous oxide. Endotracheal intubation was performed in 43.8% of the patients. Spinal anesthesia was induced in 3 patients, and peripheral neural blockage was used in 2 patients. Prothrombin time, activated partial thromboplastin time, international normalized ratio, and levels of serum alanine transaminase, aspartate transaminase, total bilirubin, blood urea nitrogen, and creatinine were similar preoperatively and on the first day after surgery (P > .05). CONCLUSIONS: In this study, neither regional nor general anesthesia was associated with a deterioration of liver function. We suggest that recipients of orthotopic liver transplant can undergo nontransplant surgery without postoperative graft dysfunction if hepatic perfusion is maintained with appropriate anesthetic management.

Incidence and Patient Outcomes in Renal Replacement Therapy After Orthotopic Liver Transplant.

OBJECTIVES: Our objective was to evaluate the incidence of renal replacement therapy after orthotopic liver transplant and to evaluate and analyze patient outcomes. MATERIALS AND METHODS: We performed a retrospective analysis of 177 consecutive patients at a tertiary care unit who underwent orthotopic liver transplant between January 2010 and June 2016. Patients who were admitted to the intensive care unit after orthotopic liver transplant and who required renal replacement therapy were included. RESULTS: A total of 177 (79 adult, 98 pediatric) orthotopic liver transplants were performed during the study period. Of these, 35 patients (19%) required renal replacement therapy during the early posttransplantation period. After excluding 5 patients with previous chronic renal failure, 30 patients (17%; 20 adult [25% ], 10 pediatric [10% ]) with acute kidney injury required renal replacement therapy. The mean patient age was 31.1 ± 20.0 years, with a mean Model for End-stage Liver Disease score of 16.7 ± 12.3. Of the patients with acute kidney injury who underwent renal replacement therapy, in-hospital mortality was 23.3% (7 of 30 patients), and 40% remained on dialysis. No significant difference was seen in mortality between early versus delayed initiation of renal replacement therapy in patients with stage 3 acute kidney injury (P = .17). CONCLUSIONS: Of liver transplant recipients who present with acute kidney injury, 19% require renal replacement therapy, and in-hospital mortality is 20% in the early postoperative period.

Perioperative Venoarterial Extracorporeal Membrane Oxygenation Support During Heart Transplant.

OBJECTIVES: Heart transplant is the only definitive treatment of end-stage heart failure. Venoarterial extracorporeal membrane oxygenation may be used as a bridge to heart transplant. This technique may be used after heart transplant for conditions refractory to medical treatment like primary graft failure. Previously, we reported our experience with patients who received extracorporeal support as a bridge to emergency heart transplant. In this study, we present our perioperative experience with heart transplants in which extracorporeal support was used. MATERIALS AND METHODS: We retrospectively screened the data of 31 patients who were seen at our center between January 2014 and June 2016. We screened for patients who were admitted tothe intensive care unit before transplant and who required venoarterial extracorporeal membrane oxygenation for circulatory support and postoperative patients who required extracorporeal support. Patient demographics and characteristics, clinical data, and extracorporeal support data were collected from our electronic database and patient medical records. RESULTS: There were 14 patients who required perioperative extracorporeal support. Preoperative support was performed in 3 patients before transplant, and postoperative support was performed in 11 patients after transplant. The mean age was 37.7 years in patients within the preoperative group and 29.7 years in patients within the postoperative group. One patient with preoperative support and 5 with postoperative support were pediatric patients. The main indication for transplant was dilated cardiomyopathy in both groups (100% and 63.7%). Overall mortality rates were 33% in the preoperative group and 63.7% in the postoperative group. CONCLUSIONS: For patients on heart transplant wait lists who are worsening despite optimal medical therapy, venoarterial extracorporeal membrane oxygenation support is a safe and viable last resort. In addition, extracorporeal support can be used during the posttransplant period as salvage therapy in heart recipients with hemodynamic deterioration. In our experience, preoperative extracorporeal support had lower mortality rates compared with postoperative support.

Effect of Graft Weight to Recipient Body Weight Ratio on Hemodynamic and Metabolic Parameters in Pediatric Liver Transplant: A Retrospective Analysis.

OBJECTIVES: To analyze how graft-weight-to-bodyweight ratio in pediatric liver transplant affects intraoperative and early postoperative hemodynamic and metabolic parameters. MATERIALS AND METHODS: We reviewed data from 130 children who underwent liver transplant between 2005 and 2015. Recipients were divided into 2 groups: those with a graft weight to body weight ratio > 4% (large for size) and those with a ratio ≤ 4% (normal for size). Data included demographics, preoperative laboratory findings, intraoperative metabolic and hemodynamic parameters, and intensive care follow-up parameters. RESULTS: Patients in the large-graft-for-size group (>4%) received more colloid solution (57.7 ± 20.1 mL/kg vs 45.1 ± 21.9 mL/kg; P = .08) and higher doses of furosemide (0.7 ± 0.6 mg/kg vs 0.4 ± 0.7 mg/kg; P = .018). They had lower mean pH (7.1 ± 0.1 vs 7.2 ± 0.1; P = .004) and PO2 (115.4 ± 44.6 mm Hg vs 147.6 ± 49.3 mm Hg; P = .004) values, higher blood glucose values (352.8 ± 96.9 mg/dL vs 262.8 ± 88.2 mg/dL; P < .001), and lower mean body temperature (34.8 ± 0.7°C vs 35.2 ± 0.6°C; P = .016) during the neohepatic phase. They received more blood transfusions during both the anhepatic (30.3 ± 24.3 mL/kg vs 18.8 ± 21.8 mL/kg; P = .013) and neohepatic (17.7 ± 20.4 mL/kg vs 10.3 ± 15.5 mL/kg; P = .031) phases and more fresh frozen plasma (13.6 ± 17.6 mL/kg vs 6.2 ± 10.2 mL/kg; P = .012) during the neohepatic phase. They also were more likely to be hypotensive (P < .05) and to receive norepinephrine infusion more often (44% vs 22%; P < .05) intraoperatively. More patients in this group were mechanically ventilated in the intensive care unit (56% vs 31%; P = .035). There were no significant differences between the groups in postoperative acute renal dysfunction, graft rejection or loss, infections, length of intensive care stay, and mortality (P > .05). CONCLUSIONS: High graft weight-to-body-weight ratio is associated with adverse metabolic and hemodynamic changes during the intraoperative and early postoperative periods. These results emphasize the importance of using an appropriately sized graft in liver transplant.

Pretreatment with simvastatin reduces lung injury related to intestinal ischemia-reperfusion in rats.

In this rat model study we evaluated whether pretreatment with simvastatin affects the severity of acute lung injury caused by intestinal ischemia-reperfusion (I/R). Twenty-four animals were randomly allocated to three equal groups (sham, control, simvastatin). The simvastatin group was pretreated with simvastatin 10 mg x kg(-1) x day(-1) for 3 days, whereas the other groups received placebo. The simvastatin and control groups underwent 60 min of superior mesenteric artery occlusion and 90 min of reperfusion. Compared with the simvastatin group, the control group exhibited significantly more severe intestinal I/R-induced acute lung injury, as indicated by lower Pao2 and oxygen saturation (P = 0.01 and P = 0.005, respectively) and higher mean values for neutrophil infiltration of the lungs (P = 0.003), total lung histopathologic injury score (P = 0.003), lung wet-to-dry weight ratio (P = 0.009), and lung-tissue malondialdehyde levels (P = 0.016). The control and simvastatin groups had similar serum levels and similar bronchoalveolar lavage fluid levels of cytokines (interleukin-1, interleukin-6, and tumor necrosis factor-alpha) and P-selectin at all measurements, except for a significantly higher level of bronchoalveolar lavage fluid P-selectin in the control group (P = 0.006). Pretreatment with simvastatin reduces the severity of acute lung injury induced by intestinal I/R in rats.

Neurologic Complications After Cardiac Transplant.

OBJECTIVES: Cardiac transplant is the best available therapy for patients with end-stage heart failure. Neurologic complications occur at a rate of 30% to 70% in patients undergoing cardiac transplant, and they affect mortality and morbidity of these patients. Risk factors for neurologic complications include immunosuppressive medication toxicity, infections, brain lesions, and metabolic disorders. The aim of our study was to determine the incidence of neurologic complications in adult patients undergoing cardiac transplant. MATERIALS AND METHODS: We retrospectively evaluated the medical records of 70 patients who underwent cardiac transplant between 2004 and April 2016. We recorded the demographic data, neurologic symptoms, neurologic examination findings, laboratory test results, brain imaging study results, and treatments received of the patients. RESULTS: Of the 70 patients enrolled, 55 were male and 15 were female patients. The age range was 18 to 63 years, and the mean age was 42.4 years. Twelve patients had encephalopathy, 4 had neuropathic pain, 3 had tremor, 2 had ischemic cerebrovascular accident, 7 had posterior reversible encephalopathy syndrome, and 1 had drop foot. Encephalopathy usually developed secondary to other neurologic disorders. The incidence of neurologic complications in adult patients undergoing cardiac transplant was 30%. CONCLUSIONS: Neurologic complications are common after cardiac transplant. We observed an incidence of 30% for neurologic complications in our clinic, with encephalopathy being the most common complication. Encephalopathy most commonly developed secondary to posterior reversible encephalopathy syndrome.

Venoarterial Extracorporeal Membrane Oxygenation Support as a Bridge to Heart Transplant: Report of 3 Cases.

Heart transplant is the only definitive treatment of end-stage heart failure. Venoarterial extracorporeal membrane oxygenation may be used as a bridge to heart transplant. Among 31 patients who underwent heart transplant between January 2014 and June 2016, we present our experiences with 3 patients who received venoarterial extracorporeal support as a bridge to heart transplant. The first patient was a 51-year-old male with ischemic dilated cardiomyopathy. Transplant was performed after 6 days of extracorporeal support, and the patient was discharged and alive at follow-up. Patient 2 was a 12-yearold girl with dilated cardiomyopathy who presented with cardiac arrest. Extracorporeal support was initiated during cardiopulmonary resuscitation. She had full neurologic recovery and remained on the wait list. She received a transplant 22 days after resuscitation. She survived and was alive at day 220 posttransplant. The third patient was a 50-year-old male with ischemic dilated cardiomyopathy requiring venoarterial extracorporeal support. Percutaneous balloon atrial septostomy was performed for left ventricle venting. He underwent transplant on day 28 after intensive care unit admission. He died 29 days after release from the hospital. Regarding patients on heart transplant wait lists who are worsening despite optimal medical therapy, venoarterial extracorporeal membrane oxygenation support is a safe and viable last resort.