Urgency or Outcome as Guiding Principle for the Allocation of Deceased Donor Livers: A Questionnaire Survey Among Outpatients of a University Medical Department in Germany.

INTRODUCTION: The sickest-first principle has been pursued in the allocation of donor livers for transplantation with the introduction of algorithms based on the model of end-stage liver disease (MELD) score. In Germany outcomes of liver transplantation appear to be negatively influenced by the transplantation of patients with very high MELD scores and the use of donor organs with lower quality. Therefore, some have claimed, allocation should be based more on outcome-oriented criteria. METHODS: A survey with binary questions (yes/no) regarding the appreciation of values concerning the allocation of donor livers was performed among general medical outpatients of a university hospital. End-stage liver disease patients were excluded. Two hundred four returned forms were analyzed. Percentages of valid answers are given. RESULTS: In this study, 88%, 73%, and 41% of subjects answered they would be willing to undergo transplantation with an estimated outcome of 20%, 50%, and 80% 1-year mortality rate, respectively, for themselves. Choosing a possible recipient between 2 case examples, 68% of valid answers voted for the case with higher age and urgency and lower long-term survival. Seventy percent said urgency was more important than long-term outcome as a criterion for organ allocation. Under the assumption that urgency-based allocation would decrease average long-term survival of liver transplantation, 58% refused to deny even the sickest patients transplantation. Seventy-eight percent said that patients likely to achieve 50% long-term survival should not be denied liver transplantation. CONCLUSION: In our study a majority of subjects prioritize urgency and granting a chance to avert imminent death over long-term survival per procedure. Equitable distribution of chances for survival may be estimated more than outcome maximization in terms of aggregate life-years gained.

Clinical manifestations and treatment options in patients with cirrhosis and diabetes mellitus.

BACKGROUND: Diabetes is frequently diagnosed in patients with cirrhosis and represents an important risk factor for morbidity and mortality. Pharmacological therapy is limited due to hepatotoxicity and the risk of hypoglycemia. Investigations on medical practice in this patient population, frequency of diabetes-associated complications and the impact of quality of metabolic control are rare. AIMS AND METHODS: A retrospective analysis was performed to compare the effects of hypoglycemic treatment, the achieved glycemic control under therapy, the prevalence of typical cirrhosis-related or microangiopathic complications, and cardiovascular comorbidities between a group of diabetic patients with cirrhosis (n = 87) and a nondiabetic cirrhotic population (n = 198). RESULTS: The prevalence of diabetes in our cohort was 30.5%. Of all diabetic patients, 39.1% received therapy which might potentially result in serious side effects in patients with end-stage liver disease. The rate of ongoing alcohol abuse (28.7%) and noncompliance under medication (41.4%) was high. Only 28.7% of all diabetic subjects showed satisfactory (as defined by HbA1c ≤ 6.5%) glycemic control under therapy. Patients achieving satisfactory control experienced a lower rate of certain cirrhosis-related complications such as hepatic encephalopathy (HE) and hepatocellular carcinoma (HCC), arterial hypertension, and hypercholesterolemia. HE was significantly more frequent in diabetic than nondiabetic cirrhotic patients.

Orthotopic liver transplantation in critically ill cirrhotic patients with multi-organ failure: a single-center experience.

Due to the lack of donor organs for orthotopic liver transplantation (OLT) in Germany, a larger proportion of patients advance to multi-organ failure (MOF) before OLT. Twenty-three patients on the waiting list for OLT were admitted to our intensive care unit (ICU) from January 2007 until September 2009. They consisted of 16 men and 7 women of median (25th-75th percentile) age of 60 years (54-65). Acute Physiology and Chronic Health Evaluation (APACHE II) score upon ICU admission was 26 (19-34); Model of End-Stage Liver Disease (MELD) score was 29 (22-41); Sequential Organ Failure Assessment (SOFA) score was 12 (8-16). The 90-day mortality rate was 39%. A decrease in MELD score during the first 48 hours (-2 [-5-0] vs 2 [-1-4]; P=.019) was associated with survival. Thirteen patients underwent transplantation from the ICU. By the time of the OLT, the MELD scores had deteriorated to 38 (33-39) and SOFA scores to 19 (18-19). All patients were mechanically ventilated and received hemodynamic support with catecholamines. Ten of 13 patients (77%) received renal replacement therapy and/or single pass albumin dialysis. Eight of 13 patients (62%) had a SOFA score of 3 or 4 (organ failure) in each of the respective subscores for the cardiovascular, renal, and respiratory systems at the time of OLT. The 90-day mortality rate after OLT was 38% and the 1-year-mortality rate was 54%. Patients who did not survive 90 days post OLT showed lower MELD scores on admission (33 [18-35] vs 44 [32-46]; P=.045), an increased MELD during the first 48 hours (3 [1-4] vs -2 [-8-1]; P=.002), and a longer ICU stay before OLT (32 [18-37] vs 8 [2-15]; P=.006). In conclusion, OLT may be successful treatment for cirrhotic patients with MOF. Outcomes of MOF in cirrhotic patients may improve after OLT but are generally worse than acceptable. A shorter ICU waiting time seemed to be beneficial.

Complications related to less-invasive haemodynamic monitoring.

BACKGROUND: The aim of this study was to evaluate the type and incidence of complications during insertion, maintenance, and withdrawal of central arterial catheters used for transpulmonary thermodilution haemodynamic monitoring (PiCCO™). METHODS: We conducted a prospective, observational, multicentre study in 14 European intensive care units (six countries). A total of 514 consecutive patients in whom haemodynamic monitoring by PiCCO™ was indicated were studied. RESULTS: Five hundred and fourteen PiCCO catheters (475 in femoral, 26 in radial, nine in axillary, and four in brachial arteries) were inserted. Arterial access was obtained on the first attempt in 86.4% of the patients. Minor problems such as oozing after insertion (3.3%) or removal of the catheter (3.5%) were observed, but no episodes of serious bleeding (more than 50 ml) were recorded. Small local haematomas were observed after insertion (4.5%) and after removal (1.2%) of the catheter. These complications were not more frequent in patients with coagulation abnormalities. The incidence of site inflammation and catheter-related infection was 2% and 0.78%, respectively. Other complications such as ischaemia (0.4%), pulse loss (0.4%), or femoral artery thrombosis (0.2%) were rare, transient, and all resolved with catheter removal or embolectomy, respectively. CONCLUSIONS: In this series of patients, central arterial catheters used for PiCCO™ monitoring were demonstrated to be a safe alternative for advanced haemodynamic monitoring.

Infected necrosis in severe pancreatitis--combined nonsurgical multi-drainage with directed transabdominal high-volume lavage in critically ill patients.

BACKGROUND: Infection of pancreatic necrosis is a life-threatening complication during the course of acute pancreatitis. In critically ill patients, surgical or extended endoscopic interventions are associated with high morbidity and mortality. Minimally invasive procedures on the other hand are often insufficient in patients suffering from large necrotic areas containing solid or purulent material. We present a strategy combining percutaneous and transgastric drainage with continuous high-volume lavage for treatment of extended necroses and liquid collections in a series of patients with severe acute pancreatitis. PATIENTS AND METHODS: Seven consecutive patients with severe acute pancreatitis and large confluent infected pancreatic necrosis were enrolled. In all cases, the first therapeutic procedure was placement of a CT-guided drainage catheter into the fluid collection surrounding peripancreatic necrosis. Thereafter, a second endosonographically guided drainage was inserted via the gastric or the duodenal wall. After communication between the separate drains had been proven, an external to internal directed high-volume lavage with a daily volume of 500 ml up to 2,000 ml was started. RESULTS: In all patients, pancreatic necrosis/liquid collections could be resolved completely by the presented regime. No patient died in the course of our study. After initiation of the directed high-volume lavage, there was a significant clinical improvement in all patients. Double drainage was performed for a median of 101 days, high-volume lavage for a median of 41 days. Several endoscopic interventions for stent replacement were required (median 8). Complications such as bleeding or perforation could be managed endoscopically, and no subsequent surgical therapy was necessary. All patients could be dismissed from the hospital after a median duration of 78 days. CONCLUSION: This approach of combined percutaneous/endoscopic drainage with high-volume lavage shows promising results in critically ill patients with extended infected pancreatic necrosis and high risk of surgical intervention. Neither surgical nor endoscopic necrosectomy was necessary in any of our patients.

Failure of current antibiotic first-line regimens and mortality in hospitalized patients with spontaneous bacterial peritonitis.

BACKGROUND: Increases in Gram-positive infections and infections with Enterobacteriaceae with antimicrobial resistance have been reported in patients with spontaneous bacterial peritonitis (SBP). This study was performed to investigate the rate of treatment failures of recommended empirical therapies and the impact on mortality. PATIENTS AND METHODS: A prospectively collected database comprising 101 patients with SBP (70 nosocomial, 31 community acquired) treated at a university hospital between 2002 and 2006 in Munich, Germany, was analyzed. RESULTS: 17 patients initially received a broader than recommended antibiotic regimen. Most of these were treated in the intensive care unit because of severe sepsis/septic shock. Hospital mortality in this group was 82%. A modification of therapy was necessary in 24 of the 84 patients receiving one of the published first-line therapies (cefotaxime, ampicillin/clavulanate, or ciprofloxacin). Mortality was significantly higher in these patients than in those with no change in treatment (66.7% vs 30%, p = 0.002). In 29 patients with positive cultures, mortality was also higher in those with an ineffective first-line treatment (90% vs 45%, p = 0.032). In the multivariable analysis, a modification of antibiotic treatment was an independent risk factor for mortality (odds ratio 5.876, 95% confidence interval 1.826-18.910, p = 0.003). In 41 culture-positive cases, the most commonly cultured pathogens were Escherichia coli (n = 17) and Enterococcus faecium (n = 10). Of the encountered bacterial microorganisms, 14 (33.3%) were resistant to cefotaxime, 17 (38.6%) were resistant to amoxicillin/clavulanate, and 19 (45.2%) were resistant to ciprofloxacin. 29 (64.4%) of the isolates were resistant to one of the recommended firstline antibiotic regimens, and 11 (24.4%) of the isolates were resistant to all three. CONCLUSION: Recommended empirical antibiotic regimens fail to achieve the desired effect in a substantial number of hospitalized patients with SBP. This has a negative impact on mortality.

Coma as a presenting symptom of primary HIV infection.

Primary HIV infection (PHI) is symptomatic in 50-90% of patients. The diagnosis, however, is seldom made at first presentation. This is probably because of the multifaceted and unspecific manifestations, the omission to perform adequate diagnostic testing and the failure to assess risks for PHI. Meningoencephalitis has been described as a fairly common presenting condition in PHI, with nuchal rigidity, fatigue, photophobia and headache; therefore, PHI should be considered in the differential diagnosis of aseptic meningitis. We present the case of a man with acute coma and a presumptive diagnosis of viral encephalitis in whom serological testing showed HIV encephalitis during PHI.

Hemodynamics after endoscopic submucosal injection of epinephrine in patients with nonvariceal upper gastrointestinal bleeding: a matter of concern.

We report about detailed hemodynamic changes and one major cardiac complication occurring after submucosal injection of epinephrine (1 : 10 000) for management of upper gastrointestinal bleeding in a series of four consecutive patients. Cardiac contractility and afterload, determined by the cardiac index and the systemic vascular resistence index (SVRI), were assessed by transpulmonary thermodilution using the Pulse Contour Cardiac Output monitoring system (PiCCO; Pulsion Medical Systems, Munich, Germany), and the mean arterial pressure and heart rate were recorded. We observed a distinct rise in both mean arterial pressure and heart rate, and this effect was pronounced in the three patients with esophageal lesions. The increase in the mean arterial pressure was caused by an elevation of the cardiac index in two patients, a rise in both cardiac index and SVRI in one patient, and a rise in the SVRI only in the fourth patient. One patient, who had received 30 ml epinephrine for treatment of a bleeding Mallory-Weiss tear, developed an acute myocardial infarction during the postprocedural follow-up period. In conclusion, submucosal injection of epinephrine may cause significant hemodynamic changes that can potentially lead to adverse cardiac events. Close cardiac monitoring during and after submucosal application of epinephrine therefore seems a prudent precaution. In the treatment of esophageal lesions, the total amount of epinephrine injected should be carefully titrated, so that the lowest possible volume that achieves adequate hemostasis is used.

Improvements in volumetric quantification of circumscribed hepatic lesions by three dimensional sonography.

The size of hepatic tumors is commonly estimated by ultrasound as well as by computed tomography by measuring the three diameters followed by computing of the volume by applicating the ellipsoid formula. Using the new technique of three-dimensional-sonography it is possible to perform volume measurement by computer-linked planimetry. Initial tests with water filled balloons of defined volume revealed the accuracy (mean error of 3.0%) and high reproducibility (low intra- and inter-observer variance) of the method applied by one investigator (intraindividual SD +/- 1.3%) as well as by four different investigators (interindividual SD +/- 2.1%). Circumscribed hepatic lesions of 63 patients were investigated by using conventional sonography (ellipsoid formula), computed tomography (ellipsoid formula) and three-dimensional-sonography (ellipsoid formula, ortrip, planimetry). As a volume of reference a mathematical approximation for infinite sonographical slices (planimetry) of a very well circumscribed hemangioma of the liver was defined. Based on these results a mean error of -6% (SD +/- 39%) was determined for conventional sonography. For computed tomography a mean error of 2+ (SD +/- 35%) was found, for three-dimensional-sonography that figure was -6% (SD +/- 5%). Follow up investigations can only demonstrate significant alterations of volume when the SD-interval is exceeded. Therefore, three-dimensional-sonography provides a more sensitive and reliable recognition of volumetric changes of liver tumors than conventional sonography or computed tomography does.

Clinical application of three-dimensional sonography in internal medicine.

Three-dimensional sonography represents a development of non-invasive diagnostic imaging by real-time two-dimensional sonography. The use of transparent rotating scans, comparable to a block of glass, generates a three-dimensional effect. The first clinical application of this technique was in the field of gynecology and obstetrics, namely in prenatal diagnostics. In this study we describe its first application in internal medicine. In preliminary examinations on healthy volunteers we obtained specific processing data for optimal imaging results. This was followed by secondary examinations on 123 patients who had previously undergone conventional sonography with pathological findings. In more than 75% of the cases examined we found an optimal reproduction of sonographic findings with respect to the evaluation criteria developed by us for the three dimensional imaging of processed data. With the inclusion of measurement parameters such as distance determination and volume measurements the data gathered will allow the generation of reproducible results. Future studies will confirm the value of this method in diagnostic imaging.