Use of tissue plasminogen activator in liver transplantation from donation after cardiac death donors.

Ischemic-type biliary stricture (ITBS) occurs in up to 50% after liver transplantation (LT) from donation after cardiac death (DCD) donors. Thrombus formation in the peribiliary microcirculation is a postulated mechanism. The aim was to describe our experience of tissue plasminogen activator (TPA) administration in DCD-LT. TPA was injected into the donor hepatic artery on the backtable (n = 22). Two recipients developed ITBS including one graft failure. Although excessive postreperfusion bleeding was seen in 14 recipients, the amount of TPA was comparable between those with and without excessive bleeding (6.4 ± 2.8 vs. 6.6 ± 2.8 mg, p = 0.78). However, donor age (41 ± 12 vs. 29 ± 9 years, p = 0.02), donor BMI (26.3 ± 5.5 vs. 21.7 ± 3.6 kg/m(2) , p = 0.03), previous laparotomy (50% vs. 0%, p = 0.02) and lactate after portal reperfusion (6.3 ± 4.6 vs. 2.8 ± 0.9 mmol/L, p = 0.005) were significantly greater in recipients with excessive bleeding. In conclusion, the use of TPA may lower the risk of ITBS-related graft failure in DCD-LT. Excessive bleeding may be related to poor graft quality and previous laparotomy rather than the amount of TPA. Further studies are needed in larger population.

Dialysis 101. Acute and chronic fluid shifts.

For over 30 years, dialysis has been accepted as a proven therapeutic intervention in sustaining life for patients with end-stage renal disease. As a renal replacement therapy, dialysis only approximates renal function. Derangements in fluids, electrolytes, and acid-base homeostasis occur in the course of progressive renal insufficiency. Nephrons are able to adapt to physiologic needs and maintain a balance for many solutes, until the very late stages of chronic renal failure. This permits survival of the patient with minimal therapeutic intervention. The availability of highly permeable membranes has allowed development of continuous renal replacement therapies that gradually remove fluids and solutes resulting in better hemodynamic stability.

Urgent colectomy in a patient with membranous tracheal disruption after severe vomiting.

IMPLICATIONS: We report a case of a patient who developed membranous tracheal disruption after severe vomiting. He subsequently required urgent colectomy for toxic megacolon under general anesthesia. With this challenging situation, we were able to successfully conduct general anesthesia in the presence of tracheal laceration, pneumothorax, and pneumomediastinum.