The effectiveness of Thromboelastography (TEG) or thromboelastometry (ROTEM) to guide transfusion treatment versus usual care in liver transplant / A eficácia da tromboelastografia (TEG) ou tromboelastometria (ROTEM) para orientar o tratamento transfusional versus o tratamento usual no transplante de fígado / La eficacia de la tromboelastografía (TEG) o tromboelastometría (ROTEM) para guiar el tratamiento de transfusión versus la atención habitual en el trasplante de hígado

ABSTRACT The accuracy of the TEG/ROTEM as diagnostic test has been proved(19) and systematic reviews were performed to aggregate the evidence from different clinical scenarios (mainly cardiac surgery). Assess the impact of the intraoperative point of care use of TEG or ROTEM versus conventional coagulation tests (CCT) on the blood components transfusion, bleeding, complications, mortality, hospitalization and costs during adult LTX surgeries. I used PICOS framework to establish the research questions (objectives section) and the inclusion criteria. Type of studies included. The eligibility criteria were randomized controlled trials and non-randomized controlled trials (RCTs and non-RCTs). Primary outcomes: mortality at maximal follow up, allogeneic transfusion requirements: packaged red cells (PRC), platelets, fresh frozen plasma(FFP), cryoprecipitates), complications (medical adverse event that may be related to the coagulation status). Secondary outcomes: blood loss (however measured by authors), total hospital stays, intensive care unit (ICU) stay, costs (of the transplant surgery or of the patient in-hospital treatment). A total of 183 studies were identified and a PRISMA-based diagram was constructed and 8 of them were selected to assess. Six articles were found in full text and were screened for inclusion and exclusion criteria. Five trials had the selected outcomes and inclusion criteria and the quality was assessed with a critical appraisal approach to identify bias and confounders. In conclusion, TEG/ROTEM directed blood products replacement in LTX might be effective in reducing FFP transfusion during the intraoperative. Further studies are required to confirm this finding and to assess the overall requirements of other blood products, bleeding mortality and complications.

RESUMEN La precisión del TEG / ROTEM como prueba de diagnóstico se ha demostrado (19) y se realizaron revisiones sistemáticas para agregar la evidencia de diferentes escenarios clínicos (principalmente cirugía cardíaca). Evaluar el impacto del uso de TEG o ROTEM en el punto de atención intraoperatoria versus las pruebas de coagulación (CCT) convencionales en la transfusión de componentes sanguíneos, sangrado, complicaciones, mortalidad, hospitalización y costos durante las cirugías de LTX en adultos. Utilicé el marco PICOS para establecer las preguntas de investigación (sección de objetivos) y los criterios de inclusión. Tipo de estudios incluidos. Los criterios de elegibilidad fueron los ensayos controlados aleatorios y los ensayos controlados no aleatorios (ECA y no controlados). Resultados primarios: mortalidad en el seguimiento máximo, requisitos de transfusión alogénica: glóbulos rojos envasados ​​(PRC), plaquetas, plasma fresco congelado (FFP), crioprecipitados, complicaciones (evento adverso médico que puede estar relacionado con el estado de coagulación). Resultados secundarios: pérdida de sangre (sin embargo, medida por los autores), estadías totales en el hospital, estadía en la unidad de cuidados intensivos (UCI), costos (de la cirugía de trasplante o del tratamiento hospitalario del paciente). Se identificaron un total de 183 estudios y se construyó un diagrama basado en PRISMA y se seleccionaron 8 de ellos para evaluar. Se encontraron seis artículos en texto completo y se examinaron para criterios de inclusión y exclusión. Cinco ensayos tuvieron los resultados seleccionados y los criterios de inclusión, y la calidad se evaluó con un enfoque de evaluación crítica para identificar sesgos y factores de confusión. En conclusión, el reemplazo de productos sanguíneos dirigidos por TEG / ROTEM en LTX podría ser eficaz para reducir la transfusión de FFP durante el tratamiento intraoperatorio. Se requieren estudios adicionales para confirmar este hallazgo y evaluar los requisitos generales de otros productos sanguíneos, la mortalidad por sangrado y las complicaciones.

RESUMO A precisão do TEG / ROTEM como teste diagnóstico tem sido comprovada (19) e revisões sistemáticas foram realizadas para agregar as evidências de diferentes cenários clínicos (principalmente cirurgia cardíaca). Avaliar o impacto do uso de TEG ou ROTEM no ponto intraoperatório versus testes convencionais de coagulação (TCC) na transfusão de hemocomponentes, sangramento, complicações, mortalidade, hospitalização e custos durante cirurgias de LTX em adultos. Eu usei o framework PICOS para estabelecer as questões de pesquisa (seção de objetivos) e os critérios de inclusão. Tipo de estudos incluídos. Os critérios de elegibilidade foram ensaios clínicos randomizados e não-randomizados controlados (ECRs e não-ECR). Desfechos primários: mortalidade no seguimento máximo, necessidade de transfusão alogênica: eritrócitos empacotados (PRC), plaquetas, plasma fresco congelado (FFP), crioprecipitados), complicações (evento adverso médico que pode estar relacionado ao estado de coagulação). Desfechos secundários: perda de sangue (porém medida pelos autores), internação total, internação em unidade de terapia intensiva (UTI), custos (da cirurgia de transplante ou do tratamento intra-hospitalar do paciente). Um total de 183 estudos foram identificados e um diagrama baseado no PRISMA foi construído e 8 deles foram selecionados para avaliação. Seis artigos foram encontrados em texto completo e foram selecionados para inclusão e critérios de exclusão. Cinco ensaios tiveram os resultados selecionados e critérios de inclusão e a qualidade foi avaliada com uma abordagem de avaliação crítica para identificar vieses e fatores de confusão. Em conclusão, o TEG / ROTEM direcionado à reposição de hemoderivados no LTX pode ser eficaz na redução da transfusão de PFC durante o intraoperatório. Mais estudos são necessários para confirmar este achado e para avaliar os requisitos gerais de outros produtos sangüíneos, sangramento da mortalidade e complicações.

Mortality Analysis of Acute Liver Failure in Uruguay.

BACKGROUND: Acute liver failure (ALF) is a syndrome with high mortality. OBJECTIVE: Describe characteristics and outcomes of patients with ALF in Uruguay, and identify factors associated with mortality. METHODS: A retrospective analysis of 33 patients with ALF was performed between 2009 and 2017. RESULTS: The patients' median age was 43 years, and 64% were women. Average Model for End-Stage Liver Disease (MELD) score at admission was 33. The median referral time to the liver transplant (LT) center was 7 days. The most common etiologies were viral hepatitis (27%), indeterminate (21%), autoimmune (18%), and Wilson disease (15%). Overall mortality was 52% (71% of transplanted and 46% of nontransplanted patients). Dead patients had higher referral time (10 vs 4 days, P = .008), higher MELD scores at admission (37 vs 28) and highest achieved MELD scores (42 vs 29; P < .001), and higher encephalopathy grade III to IV (94% vs 25%, P < .001) than survivors. Patients without LT criteria (n = 4) had lower MELD score at admission (25 vs 34, P = .001) and highest achieved MELD score (27 vs 37, P = .008) compared with the others. Patients with LT criteria but contraindications (n = 7) had higher MELD scores at admission (38 vs 31, P = .02), highest achieved MELD scores (41 vs 34, P = .03), and longer referral time (10 days) than those without contraindications (3.5 days) or those without LT criteria (7.5 days, P = .02). Twenty-two patients were listed; LT was performed in 7, with a median time on waiting list of 6 days. CONCLUSIONS: ALF in Uruguay has high mortality associated with delayed referral to the LT center, MELD score, and encephalopathy. The long waiting times to transplantation might influence mortality.

Risk Factors of Mortality After Liver Transplantation in Uruguay.

INTRODUCTION: Identification of predictive factors of mortality in a liver transplant (LT) program optimizes patient selection and allocation of organs. OBJECTIVE: To determine survival rates and predictive factors of mortality after LT in the National Liver Transplant Program of Uruguay. METHODS: A retrospective study was conducted analyzing data prospectively collected into a multidisciplinary database. All patients transplanted since the beginning of the program on July 2009 to April 2017 were included (n = 148). Twenty-nine factors were analyzed through the univariate Kaplan-Meier model. A Cox regression model was used in the multivariate analysis to identify the independent prognostic factors for survival. RESULTS: Overall survival was 92%, 87%, and 78% at discharge, 1 year, and 3 years, respectively. The Kaplan-Meier survival curves were significantly lower in: recipients aged >60 years, Model for End-Stage Liver Disease score >21, LT due to hepatocellular carcinoma (HCC) and acute liver failure (ALF), donors with comorbidities, intraoperative blood loss beyond the median (>2350 mL), red blood cell transfusion requirement beyond the median (>1254 mL), intraoperative complications, delay of extubation, invasive bacterial, and fungal infection after LT and stay in critical care unit >4 days. The Cox regression model (likelihood ratio test, P = 1.976 e-06) identified the following independent prognostic factors for survival: LT for HCC (hazard ratio [HR] 4.511; P = .001) and ALF (HR 6.346; P = .004), donors with comorbidities (HR 2.354; P = .041), intraoperative complications (HR 2.707; P = .027), and invasive fungal infections (HR 3.281; P = .025). CONCLUSION: The survival rates of LT patients as well as the mortality-associated factors are similar to those reported in the international literature.

Early Bacterial Pneumonia After Hepatic Transplantation: Epidemiologic Profile.

BACKGROUND: Postoperative pulmonary complications are major cause of morbidity and mortality in patients receiving liver transplantation (LT), particularly bacterial pneumonia occurring within the first 100 days after transplantation. Our aim in this study was to determine the incidence, microorganisms involved, associated factors, and morbidity of bacterial pneumonia presenting in the first 100 days posttransplant. METHODS: We performed a cohort study in which patients receiving liver transplantation were included prospectively in our national database (Database of Infections in Transplantation of Solid Organs). The study period was from July 14, 2009 to July 24, 2015. RESULTS: One hundred six patients were transplanted during the 6-year period. We documented 9 bacterial pneumonia cases with an incidence of 8.5 per 100 patients; 2 patients had hospital-acquired pneumonia (HAP) and 7 had ventilator-associated pneumonia (VAP). In 4 of the 9 bacterial pneumonia cases, patients presented with bacteremia. Eleven microorganisms were isolated these 9 patients. Microbiologic diagnosis methods included 5 cases of alveolar bronchoalveolar lavage (BAL), 1 case of BAL and pleural fluid puncture, 1 case of pleural fluid puncture, and 1 case through sputum study. Of the 11 isolated organisms, 9 corresponded to Gram-negative bacilli (GNB): Klebsiella spp, n = 3; Acinetobacter baumannii, n = 4; Morganella morganii, n = 1; and Pseudomonas aeruginosa, n = 1. Regarding the resistance profile, 7 presented with a multiresistance profile (MDR) and extreme resistance (XDR). Univariate analysis identified the Model for End-Stage Liver Disease (MELD) pretransplant score as a factor associated with developing pneumonia (P < .001, 95% confidence interval [CI] 2.872-10.167), and early extubation, before 8 hours posttransplant, as a protective factor (P = .008; relative risk [RR] 0.124; 95% CI 0 .041-0.377). Hospital stay was longer in patients with pneumonia compared to those without pneumonia (P < .0001, 95% CI 17.79-43.11 days). There was also an increased risk of death in patients with pneumonia (RR 17.963; 95% CI 5106-63,195). CONCLUSIONS: Early bacterial pneumonia after hepatic transplantation is associated with higher morbidity and mortality. At our center, 4 of 9 patients had bacteremia. GNB cases with MDR and XDR profiles are predominant. Early extubation is a protective factor.

Impact of a Multimodal Approach in Prevention of Surgical Site Infection in Hepatic Transplant Recipients.

INTRODUCTION: In liver transplant (LT) recipients, surgical site infection (SSI) represents an important cause of morbidity and mortality. OBJECTIVE: This study measures the impact of a multimodal approach to the incidence of surgical site infection in LT recipients. MATERIALS AND METHODS: All of the LT recipients in our department were registered on the national database in solid organ transplant. A study was performed in two analytical-interventional phases. Phase 1 took place between July 14, 2009, and February 20, 2014. Phase 2 took place between February 21, 2014, and July 15, 2015. The multimodal change implemented during phase 1 was that 0.5% alcoholic chlorhexidine and ether were applied to the surgical field; surgical prophylaxis was primarily with ampicillin/sulbactam plus cefazolin. In phase 2, 2% alcoholic chlorhexidine alone was applied to the surgical field. The prior standard prophylaxis was changed to piperacillin tazobactam administered during surgery as a continuous infusion of 13.5 g over 8 hours with a pre-incision loading dose of 4.5 g. The loading dose of piperacillin tazobactam was combined with a single dose of gentamicin of 5 mg/kg. RESULTS: One hundred eight patients have received transplants since the start of the program: 82 patients during phase one and 26 patients during phase two. During phase 1, 13 cases of SSI were recorded, representing a rate of 15.85 per 100 transplants. Sixteen micro-organisms were isolated during phase 1, of which 12 corresponded to gram-negative bacilli. With regard to resistance profiles, 13 showed multidrug resistant and extensively drug resistant profiles. During phase 2, no cases of SSI were recorded (relative risk = 0.158 [95% confidence interval 0.0873-0.255], P = .0352]. CONCLUSION: A multimodal approach allowed for the reduction of the incidence of SSI in LTs and offered a protective strategy.

Ultrasound-guided internal jugular vein catheterization: a randomized controlled trial.

INTRODUCTION: Even though advantages of ultrasound line placement seem obvious, many countries do not have easy access to such technology. This study aims to compare the degree of difficulty in central venous line placement with or without ultrasound and the incidence of complications, and to establish the effect of the operator's degree of training. METHODS: The study included 257 patients that required central venous catheterization during the study period. Patients were divided into groups according to the operator's experience: expert group (over 70 central accesses performed before the study) (n=152) and in-training or non-expert group. Procedures were randomized to "without ultrasound" (n=80 expert and 54 non-expert) and "with ultrasound" (n=72 expert and 51 non-expert). RESULTS: Catheter placements were more successful in the "expert" and in the "with ultrasound" than in the "non-expert" (88% vs 79%; p=0.04) or in the "without ultrasound" groups (91% vs 78%; p=0.005). Incidence of complications was 11.7%, with no significant difference among "with ultrasound" (8.1%) and "without ultrasound" (14.9%) groups. However, the "non-expert" group had fewer complications with the use of ultrasound (7.8% vs 24%). CONCLUSIONS: Ultrasound reduces the incidence of complications when placement is performed by inexperienced operators. Centers with residents should emphasize the necessity of ultrasound for central line catheterization. Training in ultrasound might be of paramount importance in the effectiveness of the technique.

Intraoperative hyponatremia during craniofacial surgery.

BACKGROUND: Hyponatremia is an important cause of morbidity in some groups of hospitalized children. Our aim is to describe the incidence and severity of intraoperative hyponatremia in children undergoing craniofacial surgery, and determine the associated risk factors. METHODS: A descriptive retrospective study of children who underwent primary craniofacial surgery between March 1994 and February 2008 was performed. All administered fluids contained a minimum sodium concentration of 140 mmol.l(-1). Hyponatremia was classified as follows: severe < or =125 mmol.l(-1); moderate 126-130 mmol.l(-1); and, mild 131-134 mmol.l(-1). RESULTS: Hundred and seven cases are reported. Severe, moderate and mild intraoperative hyponatremia occurred in 14 (13%), 21 (19%) and 23 (22%) children respectively. Mannitol was given to 31 (29%) children, but was not associated with the development of hyponatremia. Neither the type nor duration of surgery, type of fluid replacement nor hourly urinary output, was associated with development of hyponatremia. Most episodes of significant intraoperative hyponatremia (44%) were detected between the 2nd and the 4th hour of surgery. There were no identified neurological sequelae (e.g. coma, neurological deficit) attributable to the hyponatremia. CONCLUSION: Despite strict avoidance of low sodium solutions (<140 mmol.l(-1)), hyponatremia occurs frequently in children undergoing craniofacial surgery in our practice; and is unrelated to the administration of mannitol. Although the mechanisms are yet to be determined, anesthesiologists should be aware of this issue and be prepared to monitor and treat this potentially serious complication.

Polysomnography of adults and elderly: sleep architecture, respiration, and leg movement.

Polysomnographic data recorded from a large sample of normal, healthy, adult volunteer subjects are reported. First and second night summary values are included. Results agree remarkably well with previously published findings and the age-related differences in sleep architecture that we found are described in detail. We also discuss some of the unique methodological problems associated with developing normative sleep values.

Diabetes, erectile dysfunction, and sleep-related erections.

Sleep-related erections were assessed in conjunction with polysomnography in 100 diabetic and 400 nondiabetic men with complaints of erectile problems. We also measured bulbocavernosus reflex latency, heart rate response to deep breathing, postural-related blood pressure changes, penile arterial sufficiency, and brachial blood pressures. To investigate the relationship between diabetes and erectile capacity, the results obtained from men with and without diabetes were compared. Men with diabetes had fewer sleep-related erections, less tumescence time, diminished penile circumference increase, and lower penile rigidity than nondiabetic men. These diabetes-related differences were found regardless of the maximum penile rigidity observed. The diabetic group had less heart rate response to deep breathing and lower penile blood pressures than the nondiabetic group, but only among men with maximum penile rigidity less than 500 g. These data indicate that both neurological and vascular mechanisms are involved to a greater degree in organic diabetic impotence than in the organic erectile dysfunction that occurs in nondiabetic men. Finally, the pattern of lower values for measures of nocturnal tumescence among diabetic men, compared to nondiabetic men, occurred in all age groups, except the oldest. Among impotent men, age 65 years or older, no difference was found between men with and without diabetes. This suggests that diabetes may foreshadow some of the age-related pathophysiological processes associated with erectile dysfunction.