Crotoxin-treated macrophages stimulate ROS production and killing activity in co-cultured neutrophils

Crotoxin (CTX), the predominant toxin in Crotalus durissus terrificus snake venom (CdtV), has anti-inflammatory and immunomodulatory effects. Despite its inhibitory action on neutrophil migration and phagocytosis, CTX does not directly affect the production of reactive oxygen species (ROS) by the neutrophils. In contrast, it enhances the generation of reactive oxygen and nitrogen intermediates by macrophages. Given the importance of macrophage-neutrophil interactions in innate antimicrobial defense, the aim of this study was to investigate the effect of CTX on neutrophil ROS production and killing activity, either through CTX-treated macrophage co-culture or conditioned medium of CTX-treated macrophages. The results showed an important modulatory action of CTX on the neutrophil function as well as neutrophil-macrophage interactions, as demonstrated by the increased production of hydrogen peroxide, hypochlorous acid, nitric oxide and TNF- a , along with the increased fungicidal activity of neutrophils.

Crotoxin-Treated Macrophages Stimulate ROS Production and Killing Activity in co-cultured Neutrophils

Crotoxin (CTX), the predominant toxin in Crotalus durissus terrificus snake venom (CdtV), has anti-inflammatory and immunomodulatory effects. Despite its inhibitory action on neutrophil migration and phagocytosis, CTX does not directly affect the production of reactive oxygen species (ROS) by the neutrophils. In contrast, it enhances the generation of reactive oxygen and nitrogen intermediates by macrophages. Given the importance of macrophage-neutrophil interactions in innate antimicrobial defense, the aim of this study was to investigate the effect of CTX on neutrophil ROS production and killing activity, either through CTX-treated macrophage co-culture or conditioned medium of CTX-treated macrophages. The results showed an important modulatory action of CTX on the neutrophil function as well as neutrophil-macrophage interactions, as demonstrated by the increased production of hydrogen peroxide, hypochlorous acid, nitric oxide and TNF- a , along with the increased fungicidal activity of neutrophils.

Participação dos receptores purinérgicos na ação estimulatória da crotoxina sobre a produção de espécies reativas do oxigênio por linhagem de monócito humano (THP-1) / Participation of purinergic receptors in the stimulatory action of crotoxin on the production of reactive oxygen species by human monocyte (THP1)

Crotoxin (CTX), the major toxin of Crotalus durissus terrificus snake venom, induces immunomodulatory action, particularly on the macrophages function, crucial cells to innate defense mechanisms. In these cells, dual action of this toxin is observed, since both inhibition of some functional parameters such as spreading and phagocytosis, as well as respiratory burst (hydrogen peroxide-H2O2 generation and nitric oxide-NO generation), Lipoxin A4 (LXA4) and its stable analog (15-Epi-LXA4) secretion and glucose and glutamine metabolism increased. Recent studies have demonstrated the importance of these CTX stimulatory actions on the metabolism of macrophages for the control of infectious inflammatory response and for tumor progression. Furthermore, FPRs are crucial for the different effects of CTX on macrophage function and metabolism. In spite of these evidences, the mechanisms involved with the CTX stimulatory actions on the metabolism of these cells are not known in their entirety. Among the mechanisms involved in the regulation of energetic metabolism of macrophages, purinergic signaling is essential in the stimulation of cytokine secretion and the reactive oxygen species and reactive nitrogen species generation by macrophages, besides being receptors responsive to stimuli via FPRs. Therefore, the objective of the present project was to investigate the possible participation of purinergic receptors on the H2O2 production by CTX treated THP-1 monocytic cells and whether FPRs participate in this signaling. For this purpose, THP-1 cells were used, such as monocytes or macrophage-differentiated or LPS-stimulated cells. The results show that THP-1 monocytes, such as macrophages differentiated from THP-1, by previous incubation with PMA, showed a significant increase of H2O2 production in the presence of different concentrations of CTX. CTX-induced H2O2 production increased was also observed after 24 hours by differentiated and LPS-stimulated macrophages. Different CTX concentrations lead to a significant increase in the ATP releasing by THP-1, in the absence or presence of LPS. Furthermore, different concentrations of CTX enhanced visualization of P2Y11 purinergic receptors and FPRs in LPS-stimulated THP-1. Blocking of P2X and P2Y purinergic receptors by non-selective antagonists abolished CTX-induced H2O2 production. Blocking of the FPRs by the selective antagonist partially interfered with the production of this toxin-induced reaction. The results together demonstrate, in an unprecedented way, that human monocytes are responsive to the action stimulatory CTX on ROS production and release of ATP and demonstrate for the first time that purinergic receptors are involved in this CTX-stimulatory action, with the FPRs participation.

A Crotoxina (CTX), toxina majoritária do veneno de serpente Crotalus durissus terrificus (VCdt) acarreta ação imunomoduladora, particularmente sobre a funcionalidade de macrófagos, células fundamentais para os mecanismos da defesa inata. Nestas células, é observado o dualismo na ação desta toxina, uma vez que foi observada tanto inibição de alguns parâmetros funcionais, como espraiamento e fagocitose, quanto à estimulação do “burst” respiratório (da geração de peróxido de hidrogênio-H2O2 e óxido nítrico-NO), da secreção de lipoxina A4 (LXA4) e seu análogo estável (15-Epi-LXA4) e do metabolismo de glicose e glutamina. Estudos recentes vêm demonstrando a importância dessas ações estimulatórias da CTX sobre o metabolismo de macrófagos para o controle da resposta inflamatória infecciosa e para a progressão tumoral. Ainda, receptores para peptídeo formil (Formyl Peptide Receptors-FPRs), ligantes de LXA4/15-Epi-LXA4 são cruciais para os diferentes efeitos da CTX sobre função e metabolismo de macrófagos. Apesar dessas evidencias não são conhecidos, na sua totalidade, os mecanismos envolvidos com as ações estimulatórias da CTX sobre o metabolismo destas células. Dentre os mecanismos envolvidos na regulação do metabolismo energético de macrófagos, a sinalização purinérgica é essencial na estimulação de secreção de citocinas e na geração de espécies reativas do oxigênio e do nitrogênio por macrófagos, além de serem receptores responsivos a estímulos via FPRs. Portanto, o objetivo do presente projeto foi investigar a possível participação dos receptores purinérgicos (RPs) sobre a produção de H2O2 por células monocíticas da linhagem THP-1, tratadas com CTX e se FPRs participam desta sinalização. Para tanto, foram utilizadas as células THP-1, como monócitos ou diferenciados em macrófagos ou estimulados por LPS. Os resultados mostram que os monócitos THP-1, como macrófagos diferenciados a partir de THP-1, por meio da incubação prévia com PMA, apresentaram aumento significativo da produção de H2O2 na presença das diferentes concentrações de CTX. O aumento da produção de H2O2 induzido pela CTX também foi observado após 24 horas, por macrófagos diferenciados e estimulados com LPS. Diferentes concentrações de CTX acarretam importante aumento de liberação de ATP por THP-1, na ausência ou presença de LPS. Ainda, as diferentes concentrações de CTX induziram aumento da visualização de receptores purinérgicos P2Y11 e FPRs em THP-1 estimuladas com LPS. O bloqueio dos receptores purinérgicos P2X e P2Y por antagonistas não seletivos aboliu a produção de H2O2 induzida pela CTX. O bloqueio dos FPRs pelo antagonista seletivo interferiu parcialmente com a produção deste reativo induzido pela toxina. Os resultados em conjunto demonstram, de maneira inédita, que monócitos humanos são responsivos à ação estimulatória da CTX sobre a produção de ROS e liberação de ATP e demonstram, pela primeira vez, que receptores purinérgicos estão envolvidos nesta ação estimulatória da CTX, com a participação dos FPRs.

Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation.

AIM: To describe the thromboelastography (TEG) "reference" values within a population of liver transplant (LT) candidates that underline the differences from healthy patients. METHODS: Between 2000 and 2013, 261 liver transplant patients with a model for end-stage liver disease (MELD) score between 15 and 40 were studied. In particular the adult patients (aged 18-70 years) underwent to a first LT with a MELD score between 15 and 40 were included, while all patients with acute liver failure, congenital bleeding disorders, and anticoagulant and/or antiplatelet drug use were excluded. In this population of cirrhotic patients, preoperative haematological and coagulation laboratory tests were collected, and the pretransplant thromboelastographic parameters were studied and compared with the parameters measured in a previously studied population of 40 healthy subjects. The basal TEG parameters analysed in the cirrhotic population of liver candidates were as follows: Reaction time (r), coagulation time (k), Angle-Rate of polymerization of clot (α Angle), Maximum strenght of clot (MA), Amplitudes of the TEG tracing at 30 min and 60 min after MA is measured (A30 and A60), and Fibrinolysis at 30 and 60 min after MA (Ly30 and Ly60). The possible correlation between the distribution of the reference range and the gender, age, MELD score (higher or lower than 20) and indications for transplantation (liver pathology) were also investigated. In particular, a MELD cut-off value of 20 was chosen to verify the possible correlation between the thromboelastographic reference range and MELD score. RESULTS: Most of the TEG reference values from patients with end-stage liver disease were significantly different from those measured in the healthy population and were outside the suggested normal ranges in up to 79.3% of subjects. Wide differences were found among all TEG variables, including r (41.5% of the values), k (48.6%), α (43.7%), MA (79.3%), A30 (74.4%) and A60 (80.9%), indicating a prevailing trend to hypocoagulability. The differences between the mean TEG values obtained from healthy subjects and the cirrhotic population were statistically significant for r (P = 0.039), k (P < 0.001), MA (P < 0.001), A30 (P < 0.001), A60 (P < 0.001) and Ly60 (P = 0.038), indicating slower and less stable clot formation in the cirrhotic patients. In the cirrhotic population, 9.5% of patients had an r value shorter than normal, indicating a tendency for faster clot formation. Within the cirrhotic patient population, gender, age and the presence of hepatocellular carcinoma or alcoholic cirrhosis were not significantly associated with greater clot firmness or enhanced whole blood clot formation, whereas greater clot strength was associated with a MELD score < 20, hepatitis C virus and cholestatic-related cirrhosis (P < 0.001; P = 0.013; P < 0.001). CONCLUSION: The range and distribution of TEG values in cirrhotic patients differ from those of healthy subjects, suggesting that a specific thromboelastographic reference range is required for liver transplant candidates.

Reduced Transfusion During OLT by POC Coagulation Management and TEG Functional Fibrinogen: A Retrospective Observational Study.

UNLABELLED: Patients undergoing orthotopic liver transplantation are at high risk of bleeding complications. Several Authors have shown that thromboelastography (TEG)-based coagulation management and the administration of fibrinogen concentrate reduce the need for blood transfusion. METHODS: We conducted a single-center, retrospective cohort observational study (Modena Polyclinic, Italy) on 386 consecutive patients undergoing liver transplantation. We assessed the impact on resource consumption and patient survival after the introduction of a new TEG-based transfusion algorithm, requiring also the introduction of the fibrinogen functional thromboelastography test and a maximum amplitude of functional fibrinogen thromboelastography transfusion cutoff (7 mm) to direct in administering fibrinogen (2012-2014, n = 118) compared with a purely TEG-based algorithm previously used (2005-2011, n = 268). RESULTS: After 2012, there was a significant decrease in the use of homologous blood (1502 ± 1376 vs 794 ± 717 mL, P < 0.001), fresh frozen plasma (537 ± 798 vs 98 ± 375 mL, P < 0.001), and platelets (158 ± 280 vs 75 ± 148 mL, P < 0.005), whereas the use of fibrinogen increased (0.1 ± 0.5 vs 1.4 ± 1.8 g, P < 0.001). There were no significant differences in 30-day and 6-month survival between the 2 groups. CONCLUSIONS: The implementation of a new coagulation management method featuring the addition of the fibrinogen functional thromboelastography test to the TEG test according to an algorithm which provides for the administration of fibrinogen has helped in reducing the need for transfusion in patients undergoing liver transplantation with no impact on their survival.

Thrombelastography-guided blood product use before invasive procedures in cirrhosis with severe coagulopathy: A randomized, controlled trial.

UNLABELLED: Bleeding is a feared complication of invasive procedures in patients with cirrhosis and significant coagulopathy (as defined by routine coagulation tests) and is used to justify preprocedure use of fresh frozen plasma (FFP) and/or platelets (PLT). Thromboelastography (TEG) provides a more comprehensive global coagulation assessment than routine tests (international normalized ratio [INR] and platelet count), and its use may avoid unnecessary blood product transfusion in patients with cirrhosis and significant coagulopathy (defined in this study as INR >1.8 and/or platelet count <50 × 10(9) /L) who will be undergoing an invasive procedure. Sixty patients were randomly allocated to TEG-guided transfusion strategy or standard of care (SOC; 1:1 TEG:SOC). The TEG group would receive FFP if the reaction time (r) was >40 min and/or PLT if maximum amplitude (MA) was <30 mm. All SOC patients received FFP and/or PLT per hospital guidelines. Endpoints were blood product use and bleeding complications. Baseline characteristics of the two groups were similar. Per protocol, all subjects in the SOC group received blood product transfusions versus 5 in the TEG group (100% vs. 16.7%; P < 0.0001). Sixteen SOC (53.3%) received FFP, 10 (33.3%) PLT, and 4 (13.3%) both FFP and PLT. In the TEG group, none received FFP alone (P < 0.0001 vs. SOC), 2 received PLT (6.7%; P = 0.009 vs. SOC), and 3 both FFP and PLT (not significant). Postprocedure bleeding occurred in only 1 patient (SOC group) after large-volume paracentesis. CONCLUSIONS: In patients with cirrhosis and significant coagulopathy before invasive procedures, TEG-guided transfusion strategy leads to a significantly lower use of blood products compared to SOC (transfusion guided by INR and platelet count), without an increase in bleeding complications. Remarkably, even in patients with significant coagulopathy, postprocedure bleeding was rare, indicating that TEG thresholds should be reevaluated.

Perioperative effects of high doses of intraoperative thymoglobulin induction in liver transplantation.

AIM: To describe our single-centre experience in liver transplantation (LT) with the infusion of high perioperative thymoglobulin doses. The optimal dosage and timing of thymoglobulin(®) [antithymocyte globulin (ATG)] administration during LT remains controversial. Cytokine release syndrome, haemolytic anaemia, thrombocytopenia, neutropenia, fever and serum sickness are potential adverse effects associated with ATG infusion. METHODS: Between December 2009 and December 2010, 16 adult non-randomized patients (ATG group), receiving a liver graft from a deceased donor, received an intraoperative infusion (4-6 h infusion) of thymoglobulin (3 mg/kg, ATG: Thymoglobuline(®)). These patients were compared (case control approach) with 16 patients who had a liver transplant without ATG treatment (control group) to evaluate the possible effects of intraoperative ATG infusion. The matching parameters were: Sex, recipient age (± 5 years), LT indication including viral status, MELD score (± 5 points), international normalized ratio and platelet count (as close as possible). The exclusion criteria for both groups included the following: Multi-organ or living donor transplant, immunosuppressive therapy before transplantation, contraindications to the administration of any thymocyte globulin, human immunodeficiency virus seropositivity, thrombocytopenia [platelet < 50000/µL] or leukopenia [white blood cells < 1000/µL]. The perioperative side effects (haemodynamic alterations, core temperature variations, colloids and crystalloids requirements, and surgical time) possibly related to ATG infusion and the thromboelastographic (TEG) evaluation of the ATG effects on coagulation, blood loss and blood product transfusion were analysed during the operation and the first three postoperative days. RESULTS: Intraoperative ATG administration was associated with longer surgical procedures [560 ± 88 min vs 480 ± 83 min (control group), P = 0.013], an intraoperative core temperature more than 37 °C (50% of ATG patients vs 6.2% of control patients, P = 0.015), major intraoperative blood loss [3953 ± 3126 mL vs 1419 ± 940 mL (control group), P = 0.05], higher red blood cell [2092 ± 1856 mL ATG group vs 472 ± 632 mL (control group), P = 0.02], fresh frozen plasma [671 ± 1125 mL vs 143 ± 349 mL (control group), P = 0.015], and platelet [374 ± 537 mL vs 15.6 ± 62.5 mL (control group), P = 0.017] transfusion, and a higher requirement for catecholamines (0.08 ± 0.07 µg/kg per minutes vs 0.01 ± 0.38 µg/kg per minutes, respectively, in the ATG and control groups) for haemodynamic support. The TEG tracings changed to a straight line during ATG infusion (preanhepatic and anhepatic phases) in 81% of the patients from the ATG group compared to 6.25% from the control group (P < 0.001). Patients from the ATG group compared to controls had higher post-op core temperatures (38 °C ± 1.0 °C vs 37.3 °C ± 0.5 °C; P = 0.02), an increased need of noradrenaline (43.7% vs 6.25%, P = 0.037), received more platelet transfusions (31.5% vs 0%, P = 0.04) and required continuous renal replacement therapy (4 ATG patients vs none in the control group; P = 0.10). ATG infusion was considered the cause of a fatal anaphylactic shock and of a suspected adverse reaction that led to intravascular haemolysis and acute renal failure. CONCLUSION: The side effects and the coagulation imbalance observed in patients receiving a high dosage of ATG suggest caution in the use of thymoglobulin during LT.

Modulação envolvida na ação de macrófagos pré-tratados com crotoxina sobre a atividade secretória de neutrófilos no modelo de co-cultura

Dados da literatura têm demonstrado que a Crotoxina (CTX), toxina majoritária do venenode serpente Crotalus durissus terrificus (VCdt) apresenta efeitos imunomodulatório e anti inflamatório. Apesar das ações inibitórias sobre a migração de neutrófilos, bem como sobre a atividade fagocítica destas células, esta toxina não altera, diretamente, a atividade microbicida por neutrófilos ativados por PMA. Por outro lado, a CTX intensifica a geração dos reativos intermediários do oxigênio e do nitrogênio por macrófagos, células fundamentais para os mecanismos da defesa inata. Recentemente, nosso grupo constatou que neutrófilos, quando cocultivadosna presença de macrófagos previamente tratados com CTX ou incubados com o sobrenadante da cultura destes macrófagos, apresentaram aumento da capacidade de burstoxidativo, sobretudo após o estímulo com PMA, evidenciando que macrófagos pré-tratados com CTX atuam como indutores na ativação de neutrófilos, células que adquirem propriedadesfuncionais e metabólicas distintas, importantes para sua ação microbicida em processos fisiopatológicos...

Anaesthetic perioperative management of patients with pancreatic cancer.

Pancreatic cancer remains a significant and unresolved therapeutic challenge. Currently, the only curative treatment for pancreatic cancer is surgical resection. Pancreatic surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and mortality. Systemic, rather than surgical complications, cause the majority of deaths. Because patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex, anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical intervention. The anaesthetist plays a key role in perioperative management and can significantly influence patient outcome. To optimise overall care, patients should be appropriately referred to tertiary centres, where multidisciplinary teams (surgical, medical, radiation oncologists, gastroenterologists, interventional radiologists and anaesthetists) work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality rates. In this review, we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.

Thromboelastographic changes in liver and pancreatic cancer surgery: hypercoagulability, hypocoagulability or normocoagulability?

BACKGROUND AND OBJECTIVE: Despite clinical and laboratory evidence of perioperative hypercoagulability, alterations in haemostasis after potentially haemorrhagic oncologic surgery are difficult to predict. This study aims to evaluate the entity, the extent and the duration of perioperative coagulative alterations following pancreas and liver oncologic surgery, by the use of both routine tests and thromboelastogram (TEG). METHODS: Fifty-six patients undergoing liver (n = 38) and pancreatic (n = 18) surgery were studied. The coagulation profile was evaluated by platelet count, prothrombin time-international normalized ratio, activated partial thromboplastin time, antithrombin III and TEG at the beginning, at the end of the operation and on postoperative days 1, 3, 5 and 10. RESULTS: All preoperative coagulative screening and TEG traces were normal before incision. In the postoperative period of the liver and pancreas groups, despite an increase in prothrombin time-international normalized ratio, a reduction in antithrombin III and platelet count and normal activated partial thromboplastin time and fibrinogen, TEG evidenced a normocoagulability in the liver group, with a major tendency towards hypocoagulability in the pancreas group, as evidenced by a transient increase in R-time and K-time between postoperative days 1 and 3. During the study period, four cases of pulmonary embolism, resolved with heparin infusion, were recorded, in the absence of laboratory and thromboelastographic evidence of hypercoagulability. CONCLUSION: Despite laboratory tests evidencing hypocoagulability in both groups, TEG traces showed a normocoagulability in liver resections, whereas a transient thromboelastographic hypocoagulability was evident in patients undergoing pancreas surgery. The discrepancy between laboratory values and thromboelastographic variables was even more evident in patients undergoing major liver resections compared with minor ones. Our study supports the role of thromboelastography, despite its limitations, as a valuable tool for the evaluation of the perioperative whole coagulation process and hypercoagulability changes and to increase patient safety through better management of antithrombotic therapy.

Massive GI bleeding due to accidental ASA inhalation.

This report describes a 38-year-old man admitted to hospital for a massive rectal bleeding and syncope. He was known to have idiopathic thrombocytopenia but he had never complained of bleeding until he was admitted to hospital with uncontrolled hemorrhage. Upper and lower endoscopic examination, performed 6 hours after occurrence of bleeding, were negative for ulcers or other bleeding lesions. However, capsule endoscopy did detect diffuse areas of petechial hemorrhage and erosions in the small bowel. Thromboelastography performed on the day of admission showed a marked decrease in platelet aggregation rate, that normalized two days after. The patient recovered with conservative treatment only. Thorough questioning did not evidence relevant events apart from inhalation of a massive quantity of acetylsalicylic acid: the patient, working as a farmer, had prepared, without protection, fodder for the animals containing a great amount of acetylsalicylic acid. Bleeding had started few hours thereafter. After recovery, bleeding did not recur despite persistent thrombocytopenia.

Two-stage liver transplantation: an effective procedure in urgent conditions.

Temporary portocaval shunt and total hepatectomy is a technique used in the presence of toxic liver syndrome because of fulminant hepatic failure, hepatic trauma, primary non-function (PNF), and eclampsia. We performed this technique on four patients. An indication for anhepatic state was severe hemodynamic instability in three of them. Etiologies of these three patients were as follows: PNF after liver transplantation, ischemic hepatitis after right hepatic artery embolization, and massive reperfusion syndrome during a liver transplantation. In the fourth patient, during the liver transplantation when hepatic artery was ligated, a kidney carcinoma in the donor graft was discovered. We decided to complete the hepatectomy and to construct a temporary portocaval shunt. Mean anhepatic phases were 19 h and 15 min. All patients survived the two-stage liver transplantation procedure without major complications. Our cases demonstrated that temporary portocaval shunt while awaiting urgent liver transplantation could be an effective "bridge" in selected patients who develop toxic liver syndrome; however, a short time between portocaval shunt and transplantation and careful intensive care managements are mandatory.

Continuous right ventricular end diastolic volume and right ventricular ejection fraction during liver transplantation: a multicenter study.

Cardiac preload is traditionally considered to be represented by its filling pressures, but more recently, estimations of end diastolic volume of the left or right ventricle have been shown to better reflect preload. One method of determining volumes is the evaluation of the continuous right ventricular end diastolic volume index (cRVEDVI) on the basis of the cardiac output thermodilution technique. Because preload and myocardial contractility are the main factors determining cardiac output during liver transplantation (LTx), accurate determination of preload is important. Thus, monitoring of cRVEDVI and cRVEF should help with fluid management and with the assessment of the need for inotropic and vasoactive agents. In this multicenter study, we looked for possible relationships between the stroke volume index (SVI) and cRVEDVI, cRVEF, and filling pressures at 4 predefined steps in 244 patients undergoing LTx. Univariate and multivariate autoregression models (across phases of the surgical procedure) were fitted to assess the possible association between SVI and cRVEDVI, pulmonary artery occlusion pressure (PAOP), and central venous pressure (CVP) after adjustment for cRVEF (categorized as < or =30, 31-40, and >40%). SVI was strongly associated with both cRVEDVI and cRVEF. The model showing the best fit to the data was that including cRVEDVI. Even after adjustment for cRVEF, there was a statistically significant (P < 0.05) relationship between SVI and cRVEDVI with a regression coefficient (slope of the regression line) of 0.25; this meant that an increase in cRVEDVI of 1 mL m(-2) resulted in an increase in SVI of 0.25 mL m(-2). The correlations between SVI and CVP and PAOP were less strong. We conclude that cRVEDVI reflected preload better than CVP and PAOP.

Laboratory test variability and model for end-stage liver disease score calculation: effect on liver allocation and proposal for adjustment.

BACKGROUND: The use of the Model for End-Stage Liver Disease (MELD) score to prioritize patients on liver waiting lists must take the bias of different laboratories into account. METHODS: We evaluated the outcome of 418 patients listed during 1 year whose MELD score was computed by two laboratories (lab 1 and lab 2). The two labs had different normality ranges for bilirubin (maximal normal value [Vmax]: 1.1 for lab 1 and 1.2 for lab 2) and creatinine (Vmax: 1.2 for lab 1 and 1.4 for lab 2). The outcome during the waiting time was evaluated by considering the liver transplantations and the dropouts, which included deaths on the list, tumor progression, and patients who were too sick. RESULTS: Although the clinical features of patients were similar between the two laboratories, 36 (13.1%) out of 275 were dropped from the list in lab 1, compared to 5 (3.5%) out of 143 in lab 2 (P<0.01). The differences were mainly due to the deaths on the list (8% lab 1 vs. 2.1% lab 2, P<0.05). The competing risk analysis confirmed the different risk of dropout between the two labs independently of the MELD score, blood group, and preoperative diagnosis. The bias on MELD calculation was considered and bilirubin and creatinine values were "normalized" to Vmax of lab 1 (corrected value=measured value x Vmax lab 1/Vmax lab 2). By comparing receiver operating characteristic curves, the ability of MELD to predict the 6-month dropouts significantly increased from an area under the curve of 0.703 to 0.716 after "normalization" (P<0.05). CONCLUSIONS: Normalization of MELD is a correct and good compromise to avoid systematic bias due to different laboratory methods.

The use of intrathecal morphine for postoperative pain relief after liver resection: a comparison with epidural analgesia.

An epidural catheter is used in some institutions for postoperative analgesia after liver surgery. However, anesthesiologists may not feel comfortable leaving a catheter in the epidural space because of concern about coagulation disturbances and possible bleeding complications caused by impaired liver function. In this study, we tested a single-shot intrathecal morphine technique and compared it to a continuous epidural naropine infusion for postoperative analgesia in liver surgery. Fifty patients were randomly assigned to an epidural analgesia group (EP group; n = 25) and an intrathecal analgesia group (IN group; n = 25). The quality of analgesia assessed by a visual analog scale (VAS), the side effects, and the additional IV analgesic requirements were recorded. We did not observe any signs of cord compression. Time to first pain drug requirement was longer in the EP group compared to the IN group (25 +/- 18.5 h versus 12 +/- 10.3 h; P < 0.05). In both groups, the VAS remained less than 30 mm throughout the 48-h follow-up period. Consumption of IV morphine with a patient-controlled analgesia device in the IN group was larger (mostly from 24 to 48 h after surgery) than the EP group (12.0 +/- 5.54 mg versus 3.1 +/- 2.6 mg, respectively; P < 0.01). The incidence of vomiting was 4% in both groups, whereas the incidence of pruritus (16% versus 0%) and nausea (16% versus 4%) was more frequent in the IN group. No postdural puncture headache and no spinal hematoma occurred. After liver resection, a single dose of intrathecal morphine followed by patient-controlled morphine analgesia can provide satisfactory postoperative pain relief. The quality of this treatment, according to the VAS, is not inferior to continuous epidural analgesia up to 48 h after surgery.

Técnicas hemoterápicas em cirurgia renal percutânea em paciente testemunha de Jeová / Utilization of hemotherapic techniques in percutaneous renal surgery in Jehova's witness patient

Jehova's witeness patients deny to receive heterologous blood transfusion even under life risk. They also neither agree with auto transfusion when the their own blood is stored days or weeks before surgery procedures. Percutaneous renal surgery can have complications and, among them, intense hemorrhage that can demand for open surgery. The authors report a case of a 32 year old patient with complete coralliform lithiasis in the right kidney who was submitted to percutaneous renal surgery with removing 400 ml of total blood accompanied subsequently of hemodilution and blood reinfusion by the end of the procedure. A Compact Advanced from Dideco, an italian company, was used for blood recovering during surgery and reinfusing it after the filtration process, centrifugation and washing of red globules. In this particular, the authors describe a technical adaption for blood collection. Both procedures are accepted by Jehova's witness patients, once that the blood is not stored and there is contact with your veined system. This article aim to show a blood capture technical variant in the percutaneous renal surgery, as well as to present a method in similar procedures, once that is not used routinely in urological surgeries.

Analysis of vascular access in intestinal transplant recipients using the Miami classification from the VIIIth International Small Bowel Transplant Symposium.

BACKGROUND: Loss of vascular access in patients with intestinal failure is considered an indication for intestinal transplantation. Such patients often have one or more occluded vein sites. Venous access could be classified according to the number of occluded vessels, to facilitate pre- and postoperative management. METHODS: At the VIIIth International Small Bowel Transplant Symposium in September 2003, a new classification of vascular access in patients who were candidates for bowel transplant was proposed. The classification was then applied to stratify all patients that underwent intestinal transplantation at the University of Miami between 1998 and 2003. Data were collected on Doppler ultrasonography, angiography, and vein angioplasty in such patients. RESULTS: A total of 106 cases in 91 patients were included in the study. Based on Doppler ultrasound results, 51.9% of patients fell into class I (no thrombosed vessels), 21.7% were in class II (one occluded vessel, or positive risk factors for thrombosis), 24.5% were in class III (multiple thrombosed vessels), and 1.9% were in class IV (all vessels thrombosed). Fifteen percent of the patients required preoperative angiography to better evaluate venous access. Most of the patients that required angiography were in class III or IV, and 53.3% of patients requiring angiography needed additional venous angioplasty to achieve access. CONCLUSIONS: All patients that are referred for intestinal transplantation should undergo preliminary mapping of their venous access by Doppler ultrasound and then be assigned to a vascular access class. Those patients with multiple thrombosed vessels (class III and above) should be strongly considered for additional angiographic evaluation.

Increased prothrombin time and platelet counts in living donor right hepatectomy: implications for epidural anesthesia.

The risks and benefits of adult-to-adult living donor liver transplantation need to be carefully evaluated. Anesthetic management includes postoperative epidural pain relief; however, even patients with a normal preoperative coagulation profile may suffer transient postoperative coagulation derangement. This study explores the possible causes of postoperative coagulation derangement after donor hepatectomy and the possible implications on epidural analgesia. Thirty donors, American Society of Anesthesiology I, with no history of liver disease were considered suitable for the study. A thoracic epidural catheter was inserted before induction and removed when laboratory values were as follows: prothrombin time (PT) > 60%, activated partial thromboplastin time < 1.24 (sec), and platelet count > 100,000 mmf pound sterling (mm3). Standard blood tests were evaluated before surgery, on admission to the recovery room, and daily until postoperative day (POD) 5. The volumes of blood loss and of intraoperative fluids administered were recorded. Coagulation abnormalities observed immediately after surgery may be related mostly to blood loss and to the diluting effect of the intraoperative infused fluids, although the extent of the resection appears to be the most important factor in the extension of the PT observed from POD 1. In conclusion, significant alterations in PT and platelet values were observed in our patients who underwent uncomplicated major liver resection for living donor liver transplantation. Because the potential benefits of epidural analgesia for liver resection are undefined according to available data, additional prospective randomized studies comparing the effectiveness and safety of intravenous versus epidural analgesia in this patient population should be performed.

Living donor liver transplantation with left liver graft.

Small-for-size syndrome in LDLT is associated with graft exposure to excessive portal perfusion. Prevention of graft overperfusion in LDLT can be achieved through intraoperative modulation of portal graft inflow. We report a successful LDLT utilising the left lobe with a GV/SLV of only 20%. A 43 year-old patient underwent to LDLT at our institution. During the anhepatic phase a porto-systemic shunt utilizing an interposition vein graft anastomosed between the right portal branch and the right hepatic vein was performed. After graft reperfusion splenectomy was also performed. Portal vein pressure, portal vein flow and hepatic artery flow were recorded. A decrease of portal vein pressure and flow was achieved, and the shunt was left in place. The recipient post-operative course was characterized by good graft function. Small-for-size syndrome by graft overperfusion can be successfully prevented by utilizing inflow modulation of the transplanted graft. This strategy can permit the use of left lobe in adult-to-adult living donor liver transplantation.

Intestinal transplantation for chronic intestinal pseudo-obstruction in adult patients.

Intestinal transplantation (ITx) has become a life-saving procedure for patients with irreversible intestinal failure who can no longer be maintained on parenteral nutrition (PN). This report presents the results of our experience on ITx in patients suffering from chronic intestinal pseudo-obstruction (CIPO). Between December 30, 2000 and May 30, 2003 six adult patients affected by CIPO underwent primary ITx at our Center. Pre-transplant evaluation, indication for ITx and surgical technique are reported. On December 30 2003, the mean follow-up was 25.0 months. No peri-operative deaths occurred in the study population and five out of six patients are alive, with 1-year patient and graft survival of 83.3% and 66.6%. Although our series is limited by the number of patients, our experience suggests that ITx transplantation should be considered in adult patients suffering from CIPO and PN life-threatening complication.