Efficacy and safety of infrahepatic inferior vena cava clamping under controlled central venous pressure for reducing blood loss during hepatectomy: A randomized controlled trial.

BACKGROUND: The purpose of this study was to evaluate the effectiveness and safety of inferior vena cava (IVC) clamping for reducing blood loss during hepatectomy. METHODS: In total, 120 elective hepatectomy patients who underwent surgery from May 2016 to October 2017 were enrolled and randomized into the IVC clamping group or nonclamping group. Both groups were managed by anesthesiological techniques for CVP reduction. Blood loss and clinical parameters were analyzed for 30 days after surgery. RESULTS: Fifty-nine patients were assigned to the IVC clamping group and 61 to the non-IVC clamping group. There was a significant difference in the total blood loss between both groups, with less blood loss observed in the IVC clamping group [500 vs 600 mL, P = .006]. The transection blood loss in the IVC clamping group was also significantly lower than that in the non-IVC clamping group [300 vs 500 mL, P < .001]. However, CVP was not associated with blood loss volume. Postoperative outcomes were not significant in either group. CONCLUSIONS: IVC clamping is beneficial for reducing blood loss during hepatectomy and is safe when combined with anesthesiological techniques. If feasible, this technique should be used regardless of the CVP value.

Lacerated Liver Graft in an Open Abdomen Setting: A Case Report.

Donor scarcity is a primary problem in the development of a transplant program. The imbalance between an extremely increasing demand and the number of organs in the supply has led to an extended criteria donor approach. The successful use of donors with infectious diseases and septic shock has been reported. However, organs from deceased donors with traumatic abdominal injury and open abdomen are usually discarded due to risks of severe infections. Thus far, only 1 such case, in which a liver graft from an open abdomen was used successfully, has been reported. Herein, we report of a case of liver transplant using a traumatized liver allograft procured from a deceased donor with an open abdomen. The donor was a 16-year-old patient who had blunt abdominal trauma and severe head injury from a car accident, resulting in emergency laparotomy with suturing of the lacerated wound at the liver and abdominal packing. The donor was subsequently pronounced brain dead, and the family consented to organ donation. A multiorgan procurement was performed, and the liver was transplanted to 52-year-old patient who had multiple hepatocellular carcinomas. The postoperative course was without any infection or rejection. In conclusion, the use of donor livers with preexisting trauma in open abdomen settings can be used as alternative to expand the organ donor pool.

Predictive Factors for a Long Hospital Stay in Patients Undergoing Laparoscopic Cholecystectomy.

Background. Although the advantages of laparoscopic cholecystectomy (LC) over open cholecystectomy are immediately obvious and appreciated, several patients need a postoperative hospital stay of more than 24 hours. Thus, the predictive factors for this longer stay need to be investigated. The aim of this study was to identify the causes of a long hospital stay after LC. Methods. This is a retrospective cohort study with 500 successful elective LC patients being included in the analysis. Short hospital stay was defined as being discharged within 24 hours after the operation, whereas long hospital stay was defined as the need for a stay of more than 24 hours after the operation. Results. Using multivariable analysis, ten independent predictive factors were identified for a long hospital stay. These included patients with cirrhosis, patients with a history of previous acute cholecystitis, cholangitis, or pancreatitis, patients on anticoagulation with warfarin, patients with standard-pressure pneumoperitoneum, patients who had been given metoclopramide as an intraoperative antiemetic drug, patients who had been using abdominal drain, patients who had numeric rating scale for pain > 3, patients with an oral analgesia requirement > 2 doses, complications, and private ward admission. Conclusions. LC difficulties were important predictive factors for a long hospital stay, as well as medication and operative factors.

Metoclopramide, versus its combination with dexamethasone in the prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: a double-blind randomized controlled trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) are significant problems in laparoscopic surgery. OBJECTIVE: Compare the prophylactic use of metoclopramide and its combination with dexamethasone in the prevention of PONV in patients undergoing laparoscopic cholecystectomy (LC). MATERIAL AND METHOD: One hundred patients aged 18 to 75 with American Society of Anesthesiologists (ASA) class 1-2 who candidates for elective LC at Chiang Mai University Hospital, were included in this double-blind, randomized controlled trial (parallel design). Patients were randomly divided into two groups, by 'Block offour 'randomization. Treatment group received 8 mg dexamethasone and 10 mg metoclopramide, and control group received 10 mg metoclopramide and normal saline solution 1.6 ml. These medications were administered intravenously when the gallbladder was removedfrom gallbladder bed. All of investigators, anesthetists, patients, care providers, and outcome assessor were blinded. Patients were asked to assess their nausea and vomiting at 2, 6, 12, and 24 hours postoperatively, and at discharge. The overall score of PONV in each patient based on afour-point whole number of nausea and vomiting by verbal rating scale 0-3 (0 = no nausea and vomiting, 1 = nausea, 2 = nausea with vomiting, and 3 = repeated vomiting >2 times). RESULTS: Fifty eligible patients were randomized to each group, and all were analyzed. There were no significant differences between baseline characteristics of patients in the two groups. The combination of dexamethasone and metoclopramide indicated a greater antiemetic effect with significant statistical analysis, odds ratio = 0.25 (95% confidence interval O. 11-0.55, p = 0.001). Thepostoperative hospital stay in the combined group and metoclopramide group were, 1 day = 47 (94%) and 37 (74%), >1 day = 3 (6%) and 13 (26%), respectively (p = 0.012). There were no postoperative complications occurred in both groups. CONCLUSION: Intravenous administration of dexamethasone combined with metoclopramide had significant effects in prophylaxis of nausea and vomiting after LC and shorten the hospital stay. Clinical trials registration number: TCTR20140128001

Microbiology, resistance patterns, and risk factors of mortality in ventilator-associated bacterial pneumonia in a Northern Thai tertiary-care university based general surgical intensive care unit.

BACKGROUND: Ventilator-associated pneumonia (VAP) occurrence, causative pathogens, and resistance patterns in surgical intensive care units (SICU) are different between Western and developing Asian countries. In Thailand, resistant organisms have progressively increased in the last decade. However, the evidence describing causes of VAP and its outcomes, especially secondary to resistant pathogens, in Asian developing countries' SICUs is very limited. Therefore, the objective of this study was to describe the incidence, pathogen characteristics, and risk factors that impact mortality and patient survival following VAP in a tertiary Northern Thai SICU. METHODS: Between 2008 and 2012, VAP occurred in a total of 150 patients in Chiang Mai University's general SICUs (6.3±2.8 cases per 1,000 mechanical ventilator days). The following clinical data were collected from 46 patients who died and 104 patients who survived: microbiologic results, susceptible patterns, and survival status at hospital discharge. Antimicrobial susceptibility patterns were classified as susceptible, multidrug resistant (MDR), extensively drug resistant (XDR), and pan-drug resistant (PDR). The hazard ratio (HR) was calculated for risk factor analysis. RESULTS: Regarding the microbiology, gram negative organisms were the major pathogens (n=142, 94.7%). The first three most common organisms were Acinetobacter baumannii (38.7% of all organisms, mortality 41.4%), Klebsiella pneumoniae (17.3%, mortality 30.8%), and Pseudomonas aeruginosa (16.7%, mortality 16%) respectively. The most common gram positive organism was Staphylococcus aureus (4.0%, mortality 50%). The median day of VAP occurrence were significantly different between the three groups (P<0.01): susceptible (day 4), MDR (day 5), and XDR (day 6.5). Only half of all VAP cases were caused by susceptible organisms. Antibiotic resistance was demonstrated by 49.3% of the gram negative organisms and 62.5% of the gram positive organisms. Extensive drug resistance was evident only in Acinetobacter baumannii (30.6%) and Pseudomonas aeruginosa (1.3%). No pan-drug resistance was found during surveillance. The significant HR risk factors were age (P=0.03), resistant organisms (P=0.04), XDR (P=0.02), and acute physiology and chronic health evaluation II score (<0.01). Acinetobacter baumannii (P=0.06) and intubation due to severe sepsis (P=0.08) demonstrated a trend toward a significant increase in the HR. On the other hand, there were significantly decreased HRs in trauma patients (P=0.01). Initial administration of appropriate antibiotic therapy had a tendency toward a significant decrease in the HR (P=0.08). CONCLUSION: Gram negative organisms were the primary cause of bacterial VAP in Chiang Mai University's general SICU. Resistant strains were present in half of all VAP cases and were associated with the day of VAP onset. Regarding risk factors, age, acute physiology, chronic health evaluation II score, resistant organisms (especially XDR), and being a non-trauma patient increased the risk of mortality.