Increased incidence of transfusion-related acute lung injury during orthotopic liver transplantation: a short report.

Intractable severe pulmonary edema during Orthotopic Liver Transplant (OLT) can be a fatal perioperative complication. We sought to characterize the incidence, timing, and related risk factors of severe pulmonary edema during OLT. We performed a retrospective observational survey of OLT cases performed between 2007 and 2011 at Miami Transplant Institute. Of all 632 OLT patients, a total of 9 patients (1.4%) had severe pulmonary edema during OLT. All these patients received blood transfusions before and after reperfusion (Packed red blood cell 8.9 ± 2.6 units, Fresh frozen plasma 12 ± 3.7 units, Platelets 5.4 ± 8.6 units). Eight episodes occurred after reperfusion (89%) and 1 before reperfusion (11%). Median time interval from last blood transfusion to severe pulmonary edema was 79 min (25-257 min). In the 8 patients that developed severe pulmonary edema post reperfusion, median time interval from reperfusion to severe pulmonary edema was 34 min (15-85 min). Perioperative mortality among severe pulmonary edema cases was 11% (1 in 9). Incidence of severe pulmonary edema was 1.4% in our patient population, and this number is much higher than that reported for TRALI in other large series (0.075 to 0.12%). Despite a large dose of steroids given at reperfusion, 89% of pulmonary edema episodes occurred within 2.5 hours of reperfusion. Also, heart failure and pulmonary embolism were unlikely based on intraoperative transesophageal echocardiography findings. These results may suggest an association between TRALI and the post reperfusion syndrome during liver transplantation that warrants further investigation.

Nicardipine reverses vasoactivity associated with University of Wisconsin solution in the rat peripheral circulation.

BACKGROUND: The rapid uniform delivery of University of Wisconsin solution (UW) to the microcirculation may be compromised by its vasoactivity. METHODS: In 2 different rodent models, we tested whether UW-mediated vasoconstriction could be reversed with nicardipine. RESULTS: In the perfused, splanchnic circulation, intravascular control solutions (lactated Ringers [LR], Hextend [HEX], histidine-tryptophan-ketoglutarate [HTK]) or UW (± nicardipine) evoked pressure changes in 3 protocols (series 1; n = 35). In the cremaster muscle, topical control solutions or UW (± nicardipine) evoked vascular responses measured by video microscopy in 4 protocols (series 2; n = 47). In series 1A, 37°C UW increased perfusion pressure, but there was no change caused by LR, HEX, or HTK. In series 1B, 4°C UW caused a similar, albeit transient, increase. In series 1C, nicardipine reversed 37°C UW-mediated vasoconstriction in a dose-related manner. In series 2A, UW caused a 30%-59% constriction that varied with arteriolar branching order. In series 2B, the recovery from UW-induced vasoconstriction varied with duration of exposure, but nicardipine fully reversed residual vasoconstriction. In series 2C, cold and warm UW were equipotent, near maximal, vasoconstrictors. In series 2D, UW potentiated no-reflow. CONCLUSION: UW causes a potent temperature-independent vasoconstriction by a calcium-mediated mechanism and this effect can be mitigated with nicardipine.

Analgesia for thoracic surgery: the role of paravertebral block.

An appropriate post operative analgesia after thoracotomies is mandatory to improve the patient's outcome, reduce complications rate, morbidity, hospital cost and length of stay. In this paper we review the evidences regarding the use of paravertebral block for thoracic surgery. In particular we examine the effect of paravertebral block compared to the other technique in four major issues: analgesia, complications rate, postoperative pulmonary function and transition from acute to chronic pain. We conclude that paravertebral block is superior to intravenous analgesia in providing pain control and preserving postoperative pulmonary function while it is equal to thoracic epidural analgesia regarding this two issues. Paravertebral block has a better safety profile when compared to intravenous and thoracic epidural analgesia. Its effect on chronic pain incidence still needs further studies.

Epidemiologic assessment of mortality, building collapse pattern, and medical response after the 1992 earthquake in Turkey. Disaster Reanimatology Study Group (DRSG).

BACKGROUND: Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey. METHODS: The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern. RESULTS: There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a "soft" first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p < 0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p < 0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p < 0.001). CONCLUSIONS: During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store front windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.

An analysis of prehospital mortality in an earthquake. Disaster Reanimatology Study Group.

INTRODUCTION: Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy. METHODS: A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991. RESULTS: Fifty-four deaths occurred prior to hospitalization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p < .01) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death. CONCLUSIONS: A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life-saving potential in these events.

Emergency medical services during the siege of Sarajevo, Bosnia and Herzegovina: a preliminary report.

BACKGROUND: The siege of Sarajevo is a long-term, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied. METHODS: In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired--the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes. RESULTS: Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury. CONCLUSIONS: Continuous needs assessment of a civilian population in a war zone should be accompanied by rapid delivery of outside aid. International "peacekeeping" forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life-supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo.

Recommendations for Life-Supporting First-Aid training of the lay public for disaster preparedness.

In catastrophic disasters such as major earthquakes in densely populated regions, effective Life-Supporting First-Aid (LSFA) and basic rescue can be administered to the injured by previously trained, uninjured survivors (co-victims). Administration of LSFA immediately after disaster strikes can add to the overall medical response and help to diminish the morbidity and mortality that result from these events. Widespread training of the lay public also may improve bystander responses in everyday emergencies. However, for this scheme to be effective, a significant percentage of the lay population must learn in eight basic steps of LSFA. These have been developed by the International Resuscitation Research Center in collaboration with the World Association for Emergency and Disaster Medicine, the City of Pittsburgh Department of Public Safety, and the American Red Cross (Pennsylvania chapter). They include: 1) scene survey; 2) airway control; 3) rescue breathing (mouth-to-mouth); 4) circulation (chest compressions; may be omitted for disasters, but should be retained for everyday bystander response); 5) abdominal thrusts for choking (may be omitted for disasters, but retained for everyday bystander response); 6) control of external bleeding; 7) positioning for shock; and 8) call for help.

Guidelines for rescue training of the lay public.

The fundamental goal of emergency medical response in disaster is to save lives and reduce injury and permanent disability. It has been observed that urgent emergency medical care of seriously injured earthquake casualties trapped under building rubble, cannot be provided unless the victims have been extricated and transported to medical facilities by friends or relatives, or are accessible to field rescue and medical teams. Equally important is the fact that extrication of seriously injured, trapped victims by laypersons is hazardous, unless the following conditions are met: 1) the rescuer has basic knowledge of extrication, and; 2) there is early application of effective life-supporting first-aid (LSFA) and/or advanced trauma life support (ATLS) at the scene. Time is the critical factor in such an effort. In previous studies of death and dying in earthquakes, it was noted that extrication of trapped victims will be attempted by survivors. Therefore, it is suggested that citizens living in regions of high seismic risk and trained in basic search and rescue and in LSFA are the most immediate resource for early response after an earthquake. An accompanying paper addresses the issue of citizen LSFA training. This paper focuses on the basic concepts of search and rescue training for the lay public.

National medical response to mass disasters in the United States. Are we prepared?

Preparing for a resuscitation response to mass disasters, such as major earthquakes or industrial disasters, requires revisions of present local, regional, and national disaster plans. These should include the following: (1) life-supporting first aid and basic rescue capability of the lay public; (2) advanced trauma life support and advanced (heavy) rescue capability brought quickly to the scene from local and surrounding (regional) emergency medical services systems; and (3) trauma hospitals sending medical resuscitation teams to, and receiving casualties from, the disaster scene for resuscitative surgery and definitive care. Local and regional everyday emergency medical services systems would respond first. The armed forces should help, at least for transport and security. We propose that the National Disaster Medical System replace its civil defense model with an emergency medical services model, designed to mobilize rapid support for local emergency medical services systems from regional, state, and national resources. Coordination should be by one federal agency, such as the Federal Emergency Management Agency, which, however, needs to focus more on resuscitation through physician input.

Cardiac function after hepatic ischemia-anoxia and reperfusion injury: a new experimental model.

BACKGROUND AND METHODS: During liver transplantation, reperfusion of the donor liver and in the clinical setting, end-stage liver disease, have occasionally resulted in profound cardiovascular disturbances. The etiology of hepatic injury-induced myocardial dysfunction is still unclear. In this study, the aims were to develop an experimental model that would facilitate the study of the effects of hepatic failure on myocardial function and to determine whether hepatic ischemia or anoxia and reperfusion injury of similar duration would result in the same degree of hepatic failure. Seventy male Sprague-Dawley rats were used as organ donors. Three simultaneous liver-heart perfusions (corresponding to three groups) were established using a modified Krebs-Henseleit buffer with 2% bovine albumin, membrane oxygenation, and a peristaltic pump. Group 1 (n = 10) and group 2 (n = 15) experiments consisted of liver-heart perfusions after 90 mins of normothermic hepatic ischemia or 90 mins of hepatic anoxia, respectively, followed by reoxygenation and 60 mins of reperfusion. Group 3 (n = 8) experiments consisted of sham liver-heart perfusions studied over the same experimental time period (60 mins). Myocardial function variables, liver function tests, arterial blood gases, and electrolytes were measured at baseline and at 3-, 10-, 30-, and 60-min intervals during reperfusion in all experiments. RESULTS: Ischemia or anoxia-induced hepatic failure resulted in a similar degree of hepatic dysfunction. Both forms of acute hepatic failure caused significant increases in liver function tests, a reduction in heart rate (p less than .05), coronary flow (p less than .05), and an increase in calculated coronary vascular resistance (p less than .05). There were no changes in buffer pH, CO2, or ionized calcium that could explain the coronary vasoconstriction. CONCLUSIONS: Hepatic dysfunction induced by ischemia or anoxia of similar duration results in a similar hepatic metabolic profile during reperfusion and can cause direct myocardial dysfunction of the isolated perfused rat heart.

Resuscitation medicine including the management of severe trauma

Resuscitation potentials have documented for everyday emergency medical services, multicasualty incident type disasters, and conventional wars. Resuscitation potentials in mass disasters, like major earthquakes, are highly suspect; for nuclear power plant accidents are unknown but must be prepared for; and for nuclear war are zero. Modelling studies are needed to evaluate the cost-effectiveness for resuscitative preparedness for major industrial disaster, earthquakes, volcanic explosions, floods, storms, major fires and other mass disasters. Resuscitation medicine, if applied with reason and compassion, by trying to achieve useful survival for as amny victims as possible, should be considered not only on the basis of numerical results, but also for its philosophical impact. Medicine in general and resuscitation medicine in particular represent an imposition of human values on thr species-orientayed random processes nature on earth (AU)