ABSTRACT
Liver transplantation (LTX) using donors after controlled circulatory death (cDCD) is associated with poorer graft survival and increased incidence of nonanastomotic biliary strictures (NASs) compared to livers procured from brain-dead donors (DBD). The use of normothermic regional perfusion (NRP) during cDCD procurement may improve posttransplant outcomes and reduce the incidence of NAS. In Sweden, cDCD LTX was introduced through a national pilot protocol with mandatory NRP. This study aims to evaluate the outcome of cDCD LTX during the pilot period. Donor and recipient data were collected on all cDCD liver transplants during the pilot period between January 2020 to December 2022. Outcome on NAS, patient and graft survival, early allograft dysfunction, acute kidney injury, and comprehensive complication index was compared to a matched cohort of 28 patients transplanted with a DBD liver between 2018 and 2022. Eighteen patients were transplanted with a liver from a cDCD donor after using NRP. The mean functional warm ischemia time was 29 ± 6 minutes. The mean lactate reduction during NRP was 8.7 ± 2.4 mmol/L, and the end NRP perfusate alanine aminotransferase was 1.4 ± 1 µkat/L. When comparing recipients of cDCD liver transplant to DBD, no significant differences were observed in the incidence of NAS, patient and graft survival, comprehensive complication index, early allograft dysfunction, or acute kidney injury. Study protocol magnetic resonance cholangiopancreatography in cDCD patients showed no signs of subclinical biliary strictures. Evaluation of the Swedish national pilot of cDCD LTX with mandatory NRP shows comparable outcomes to a matched DBD cohort with 94.4% 1-year patient and graft survival and no incidence of NAS within the first year.
ABSTRACT
Decisions to withdraw life sustaining treatment in the ICU are common, but there is little information about how treatment should be withdrawn. A pilot study showed that doctors withdraw life sustaining treatment in different ways even in identical cases. This variation can cause stress for ICU staff and relatives. Our study investigated the decisions of doctors working in ICUs in Sweden regarding the withdrawal of life sustaining treatment for two fictitious patients. There was variation in if and how drug treatments should be withdrawn, as well as how ventilatory support should be withdrawn. Less experienced doctors tended to choose to prolong the dying process by weaning, even if it is unclear if that is preferable for the staff or for relatives. Our study could be used in discussions in ICUs to try to understand how individual doctors make decisions about withdrawing life sustaining treatment.
Subject(s)
Intensive Care Units , Withholding Treatment , Humans , Withholding Treatment/legislation & jurisprudence , Sweden , Pilot Projects , Life Support Care , Attitude of Health Personnel , Male , Female , Clinical Decision-Making , Clinical Competence , Surveys and Questionnaires , Practice Patterns, Physicians' , Terminal Care , Middle Aged , Physicians/psychologyABSTRACT
BACKGROUND: Guidelines emphasize the clinician to consider the use of ultrasound to determine the cause of cardiac arrest. In this study we aimed to investigate how focused cardiac ultrasound (FOCUS) shortly after return of spontaneously circulation (ROSC) was associated with the use of further diagnostic measures and if the detection of pulmonary embolism, cardiac tamponade and acute myocardial infarction could be improved. METHODS: A retrospective, single-center, observational study at a tertiary hospital to evaluate FOCUS performed by cardiologists within 60â¯min after ROSC. Included were adult cardiac-arrest patients with ROSC, without restrictions in care. Excluded were patients with ECGs demonstrating ST elevation, patients with an obvious non-cardiac cause of cardiac arrest and patients where FOCUS was not performed. RESULTS: Between January 2012 and December 2017, FOCUS was performed in 237 (182 OHCA and 55 IHCA) patients. FOCUS findings influenced management and led to further immediate diagnostic measures in 52 (21.9%) patients. Left-ventricular regional wall motion abnormalities influenced the decision to perform emergency coronary angiography in 17 (7.2%) patients, of which nine were treated with PCI. Right-ventricular dilatation and/or pressure overload influenced a decision to perform computerized tomography of the thorax in 21 (8.9%) patients, of which 11 were diagnosed with pulmonary embolism. Cardiac tamponade was found in three patients (1.2%). CONCLUSION: The retrospective data on this cardiac-arrest population supports that ALS-conformed post-resuscitation care could include FOCUS as an adjunctive diagnostic measure shortly after ROSC.