Early Measurement of Indocyanine Green Clearance Accurately Predicts Short-Term Outcomes After Liver Transplantation.

BACKGROUND: There are no accurate tools to predict short-term mortality or the need for early retransplantation after liver transplantation (LT). A noninvasive measurement of indocyanine green clearance, the plasma disappearance rate (PDR), has been associated with initial graft function. METHODS: We evaluated the ability of PDR to predict early mortality or retransplantation after LT. In this observational prospective study, 332 LT were analyzed. Donor, recipient, and intraoperative data were investigated. The ensuing score was prospectively evaluated in a validation cohort of 77 patients. RESULTS: Thirty-three patients reached the main endpoint. By multivariate analysis, the only independent predictors of the endpoint were PDR (odds ratio [OR], 0.85; 95% confidence interval, 0.79-0.92) and international normalized ratio (OR, 1.45; 95% confidence interval, 1.17-1.82). A risk score weighted by the OR was built using cutoff values of 2.2 or greater for international normalized ratio (1 point) and less than 10%/min for PDR (2 points). Four categories (0 to 3) were possible. The risk of early death or retransplantation was associated with the score (0, 4.4%; 1, 6.5%; 2, 12%; and 3, 50%; χ for trend, P < 0.001). The score was also associated with duration of mechanical ventilation and intensive care unit stay. The score had a good diagnostic performance in the validation cohort (sensitivity, 60%; specificity, 95.5%; positive predictive value, 66.7%; negative predictive value, 94.1%). CONCLUSIONS: A simple score obtained within the first day after LT predicts short-term survival and need for retransplantation and may prove useful when selecting diagnostic and therapeutic strategies.

Extravascular Lung Water and Pulmonary Vascular Permeability Index Measured at the End of Surgery Are Independent Predictors of Prolonged Mechanical Ventilation in Patients Undergoing Liver Transplantation.

BACKGROUND: Pulmonary edema (PE) after orthotopic liver transplantation (OLT) may compromise the postoperative course and prolong the duration of mechanical ventilation (MV) and intensive care unit length of stay. Hemodynamic monitoring with transpulmonary thermodilution permits quantification of extravascular lung water index (ELWI) and calculation of the pulmonary vascular permeability index (PVPI), which is the ratio between the ELWI and the pulmonary blood volume. This ratio can discriminate between PE hydrostatic and nonhydrostatic PE. We investigated the relationship between ELWI and PVPI values, measured at the end of surgery, and prolonged MV (PMV) in patients after OLT. METHODS: We retrospectively studied 93 consecutive patients who underwent OLT. We recorded preoperative data including spirometry, echocardiography, severity liver disease with the Model for End-Stage Liver Disease score, and the Child-Pugh classification scores. Intraoperatively, we performed hemodynamic measurements with transpulmonary thermodilution and pulmonary arterial catheters after the induction of anesthesia, 10 minutes before reperfusion, and at the end of surgery. Moreover, we recorded the length of surgery, the amount of IV volume infused, the results of blood coagulation analyses, and blood transfusion. Postoperatively, we recorded the duration of MV and intensive care unit length of stay, mortality, and graft function. Patients were then classified as requiring PMV (>48 hours after surgery) or not. Statistical analyses, preoperative and intraoperative variables between patients with and without PMV, were compared using Mann-Whitney U tests. Receiver-operating characteristic curves were used to evaluate the ability of preoperative and intraoperative variables to predict PMV. RESULTS: Twelve patients required PMV after surgery. Patients who required PMV exhibited increased ELWI (11.6 ± 3 mL/kg vs 9.3 ± 2 mL/kg, P = 0.0099) and PVPI values (2.94 ± 1 vs 1.8 ± 0.6, P = 0.000015) at the end of surgery. The areas under the receiver-operating characteristic curve were 0.890 ± 0.04 for PVPI with a 99% confidence interval of 0.782 to 0.958 and 0.730 ± 0.08 for ELWI with a 99% confidence interval of 0.594 to 0.839. Using a cutoff of 2.3 for PVPI allowed a sensitivity = 91.7%, a specificity = 83.8, a positive predictive value = 45.8%, and a negative predictive value = 98.5% for predicting PMV. A cutoff of 12 for ELWI allowed a sensitivity of 50%, specificity of 85%, positive predictive value of 33.3%, and negative predictive value of 91.9% for PMV. CONCLUSIONS: PVPI and ELWI values obtained at the end of OLT are useful for predicting the need for postoperative PMV.

[Department of anesthesia, resuscitation and critical care]. / Departamento de anestesia, reanimación y cuidados intensivos.

The present study describes the impact on the Department of Anesthesiology, Resuscitation and Critical Care of treating the victims of the 11 March terrorist attack, both on the day of the attack and on subsequent days. Of the 182 victims who were hospitalized, 61 had a poor prognosis, 24 had a very poor prognosis, 2 were already dead, and a further 2 died that day. Twenty-seven patients were admitted to the critical care unit. Patients with suspected severe injuries were sent to postanesthesia recovery units, where a second level of triage was performed, allowing patients to be appropriately transferred according to their severity and the necessary interventions to be performed.

Departamento de Anestesia, Reanimación y Cuidados Intensivos / Department of Anesthesia, Resuscitation and Critical Care

El presente trabajo tiene como objetivo dar a conocer el impacto que supuso para el Departamento de Anestesia, Reanimación y Cuidados Intensivos la asistencia el 11 de marzo a las víctimas del atentado, tanto ese día como en los sucesivos. De los 182 pacientes procedentes del atentado que ingresaron, 61 fueron calificados con pronóstico grave, 24 como muy grave, 2 ingresos eran cadáveres y 2 pacientes murieron a lo largo del día. Un total de 27 pacientes ingresaron en las Unidades de Cuidados Críticos. A los pacientes con sospecha de gravedad se les trasladó a las Unidades de Recuperación Postanestésica, donde se estableció otro segundo paso de triage, lo que permitió ubicar de forma adecuada a los pacientes en función de su gravedad y realizar de forma progresiva cuantas intervenciones fueron necesarias (AU)

The present study describes the impact on the Department of Anesthesiology, Resuscitation and Critical Care of treating the victims of the 11 March terrorist attack, both on the day of the attack and on subsequent days. Of the 182 victims who were hospitalized, 61 had a poor prognosis, 24 had a very poor prognosis, 2 were already dead, and a further 2 died that day. Twenty-seven patients were admitted to the critical care unit. Patients with suspected severe injuries were sent to postanesthesia recovery units, where a second level of triage was performed, allowing patients to be appropriately transferred according to their severity and the necessary interventions to be performed (AU)

Proteínas de choque térmico en el estrés quirúrgico: toracotomía frente a herniorrafia / Heat shock proteins in surgical stress: thoracotomy vs herniorrhaphy

Introducción. El estrés quirúrgico y anestésico libera citocinas y especies reactivas de oxígeno capaces de inducir la síntesis de las proteínas de choque térmico (HSP), proteínas con propiedades inmunomoduladoras y potentes autoantígenos. Se pretende estudiar la biología de las HSP70 intraleucocitarias y la posible respuesta autoinmunitaria desencadenada por 2 tipos diferentes de agresión quirúrgica. Pacientes y método. Grupo I: grupo control con 3 pacientes. Grupo II: grupo de toracotomía, cirugía radical y anestesia general, con 6 pacientes. Grupo III: grupo de cirugía poco radical, herniorrafia y raquianestesia, con 4 pacientes. Se analizaron HSP70 intraleucocitarias y anticuerpos anti-HSP70i, antes (T0) y 24 h después de la intervención (T1).Resultados. El 50 por ciento de los pacientes expuestos a toracotomía presentó un significativo descenso del contenido de HSP intracelulares en el postoperatorio, simultáneo al incremento de los valores de autoanticuerpos anti-HSP70i. El grupo de pacientes expuestos a herniorrafia con anestesia locorregional no desarrolló respuesta autoinmunitaria. Conclusiones. En el limitado número de pacientes estudiados, la enfermedad neoplásica y la mayor agresividad de la toracotomía parecen asociarse con una reducción de las HSP en comparación con lo que sucede en los pacientes más sanos a los que se les realizó una herniorrafia. La disminución de las HSP fue simultánea a la presencia de autoanticuerpos circulantes. No se observó relación entre el estado inmunitario previo y la respuesta autoinmunitaria en el postoperatorio inmediato (AU)