Management of liver failure in general intensive care unit.

OBJECTIVE: To produce French guidelines on Management of Liver failure in general Intensive Care Unit (ICU). DESIGN: A consensus committee of 23 experts from the French Society of Anesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Association for the Study of the Liver (Association française pour l'étude du foie, AFEF) was convened. A formal conflict-of-interest (COI) policy was developed at the start of the process and enforced throughout. The entire guideline process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were ungraded. METHODS: Two fields were defined: acute liver failure (ALF) and cirrhotic patients in general ICU. The panel focused on three questions with respect to ALF: (1) Which etiological examinations should be performed to reduce morbidity and mortality? (2) Which specific treatments should be initiated rapidly to reduce morbidity and mortality? (3) Which symptomatic treatment should be initiated rapidly to reduce morbidity and mortality? Seven questions concerning cirrhotic patients were addressed: (1) Which criteria should be used to guide ICU admission of cirrhotic patients in order to improve their prognosis? (2) Which specific management of kidney injury should be implemented to reduce morbidity and mortality in cirrhotic ICU patients? (3) Which specific measures to manage sepsis in order to reduce morbidity and mortality in cirrhotic ICU patients? (4) In which circumstances, human serum albumin should be administered to reduce morbidity and mortality in cirrhotic ICU patients? (5) How should digestive haemorrhage be treated in order to reduce morbidity and mortality in cirrhotic ICU patients? (6) How should haemostasis be managed in order to reduce morbidity and mortality in cirrhotic ICU patients? And (7) When should advice be obtained from an expert centre in order to reduce morbidity and mortality in cirrhotic ICU patients? Population, intervention, comparison and outcome (PICO) issues were reviewed and updated as required, and evidence profiles were generated. An analysis of the literature and recommendations was then performed in accordance with the GRADE® methodology. RESULTS: The SFAR/AFEF Guidelines panel produced 18 statements on liver failure in general ICU. After two rounds of debate and various amendments, a strong agreement was reached on 100% of the recommendations: six had a high level of evidence (Grade 1 ±), seven had a low level of evidence (Grade 2 ±) and six were expert judgments. Finally, no recommendation was provided with respect to one question. CONCLUSIONS: Substantial agreement exists among experts regarding numerous strong recommendations on the optimum care of patients with liver failure in general ICU.

Multiplate® evaluation of acetylsalicylic acid efficacy in carotid surgery: routine and genetic influencing factors.

Essentials Acetylsalicylic acid (ASA) is prescribed to patients scheduled for carotid endarterectomy (CEA). We measured ASA efficacy during CEA by Multiplate® and searched for influencing factors. Most patients scheduled for CEA and treated by ASA are sensitive to this therapy. Influencing genomic factors are involved in ASA metabolism and in platelet function modulations. SUMMARY: Background Acetylsalicylic acid (ASA) is recommended before, during and after carotid endarterectomy (CEA). The efficacy of ASA is influenced by numerous biological and genotypic factors. Objectives To determine the biological efficacy of ASA by using the Multiplate® method, and to explore the biological parameters and genomic factors influencing this efficacy. Methods This descriptive cross-sectional study included all patients scheduled for CEA between January 2012 and April 2013. Multiplate® tests were performed at day 0 and day 30. A set of 66 single-nucleotide polymorphisms (SNPs) from 38 genes or DNA regions were selected and studied along with phenotypic parameters by the use of hierarchical clustering (HC) for multidimensional data management. Results Fifty-five patients receiving ASA were analyzed. Of the patients, 95% were found to be sensitive to ASA, with values under the threshold of normality (400 AU min-1 ). However, there were notable differences in residual aggregation among subjects over a wide range. HC revealed four subclusters comprising three categories of parameters: (i) routine and functional parameters - in ASA-treated patients, the ASPItest was highly linked to the ADPtest, to platelet count, and, to a lesser extent, to fibrinogen and hematocrit; (ii) polymorphisms in genes involved in ASA absorption and in the arachidonic acid pathway (ABCB1 and COX-1); and (iii) polymorphisms in genes modulating basal platelet function, i.e. TBXA2R, ADRA2A, PEAR1, ITGA2 and ITGB1. Conclusion Most patients treated with ASA before CEA were sensitive to it, according to Multiplate® ASPItest results. Genomic factors influencing this efficacy are SNPs involved in ASA absorption and metabolic pathway, and in modulations in basal platelet function.

Liver Transplantation With Old Grafts: A Ten-Year Experience.

BACKGROUND: The persistent scarcity of donors has prompted liver transplantation teams to find solutions for increasing graft availability. We report our experience of liver transplantations performed with grafts from older donors, specifically over 70 and 80 years old. PATIENTS AND METHODS: We analyzed our prospectively maintained single-center database from January 1, 2005, to December 31, 2014, with 380 liver transplantations performed in 354 patients. Six groups were composed according to donor age: <40 (n = 84), 40 to 49 (n = 67), from 50 to 59 (n = 62), from 60 to 69 (n = 76), from 70 to 79 (n = 64), and ≥80 years (n = 27). RESULTS: Donors <40 years of age had a lower body mass index, died more often from trauma, and more often had cardiac arrest and high transaminase levels. In contrast, older donors (≥70 years of age) died more often from stroke. Recipients of grafts from donors <50 years of age were more frequently infected by hepatitis C virus; recipients of oldest grafts more often had hepatocellular carcinoma. Cold ischemia time was the shortest in donors >80 years of age. Patient survival was not significantly different between the groups. In multivariate analysis, factors predicting graft loss were transaminase peak, retransplantation and cold ischemia time but not donor age. CONCLUSIONS: Older donors >70 and >80 years of age could provide excellent liver grafts.

Risk factors for bleeding and transfusion during orthotopic liver transplantation.

OBJECTIVE: While orthotopic liver transplantation (OLT) can be associated with haemorrhage, the risk factors for bleeding and transfusion remain difficult to predict. Perioperative transfusion has potentially deleterious side effects and impairs graft and patient survival. Preoperative identification of patients at high risk of bleeding is of clinical interest to manage perioperative transfusion and blood product storage. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: All OLT conducted between 2004 and 2008 in the University Hospital of Bordeaux were studied. Risk factors for bleeding greater than one blood volume and for massive red blood cell (RBC) transfusion were determined using univariate and multivariate analysis. Thresholds were determined with ROC curve analysis. RESULTS: One hundred and forty-eight transplantations were studied. Preoperative haemoglobin and Child class A were independent protective risk factors for bleeding greater than one blood volume (OR 0.81 [0.67-0.98] and 0.27 [0.10-0.72], respectively). Preoperative Hb was a protective risk factor (OR 0.71 [0.58-0.88]) whereas history of oesophageal varicose bleeding was a risk factor (OR 4.67 [1.45-15.05]) for transfusion of more than eight RBC. CONCLUSION: Risk factors for bleeding and transfusion during OLT identified in this study were of little clinical usefulness so blood products should always be available during the procedure.

Continuous non-invasive arterial pressure measurement: evaluation of CNAP device during vascular surgery.

OBJECTIVE: Standard non-invasive blood pressure (BP) monitoring is an intermittent, discontinuous procedure. Beat-to-beat BP monitoring requires invasive measurement via an arterial catheter and may be associated with serious complications. The Infinity CNAP SmartPod (Dräger Medical AG & Co. KG, Lübeck, Germany) has recently been proposed for non-invasive continuous beat-to-beat BP measurements. The present study was designed to compare BP obtained with the CNAP and with an invasive method in the operating room. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: Twenty-five patients undergoing major vascular surgery were included. Systolic, mean and diastolic BP were monitored invasively (SAP, MAP and DAP respectively) and not invasively using the CNAP (CNAP-S, CNAP-M and CNAP-D respectively). Measurements were performed intraoperatively every minute during 1 hour. RESULTS: One thousand and five hundred pairs of simultaneous CNAP and invasive BP measurements were obtained and 148 were eliminated. The range of BP measurements was 63-205 mmHg for SAP and 57-187 mmHg for CNAP-S, 38-143 mmHg for MAP and 43-142 mmHg for CNAP-M, 29-126 mmHg for DAP and 33-121 mmHg for CNAP-D. Bias and 95% limit of agreement between CNAP and invasive BP measurements were respectively 7.2 and -17.7 to 32.2 mmHg for SAP, -1.8 and -22.0 to 18.3 mmHg for MAP, and -7.5 and -27.3 to 12.4 mmHg for DAP. The percentage of CNAP measurements with a bias <10% with the arterial line was 69%, 86% and 91% for systolic, diastolic and mean pressures, respectively. CONCLUSION: Despite low accuracy for SAP and DAP measurements, CNAP system seems more accurate for MAP measurement in patients undergoing vascular surgery.

Rotation thromboelastometry detects thrombocytopenia and hypofibrinogenaemia during orthotopic liver transplantation.

BACKGROUND: Orthotopic liver transplantation can be associated with haemorrhage, particularly in patients with severe liver dysfunction. We assessed the value of rotation thromboelastometry (ROTEM) to monitor coagulation in the operating theatre, its correlation with routine laboratory findings, and its ability to guide platelet (Plt) and fibrinogen (Fg) transfusion. METHODS: Twenty-three patients were included in this prospective observational study. Laboratory tests and ROTEM tests (EXTEM, INTEM, FIBTEM, and APTEM) were performed six times during the procedure. Correlations between laboratory findings and ROTEM parameters were sought. Thresholds for ROTEM parameters were determined with receiver-operating characteristic (ROC) curve analysis according to Plt count and Fg levels. RESULTS: Clot amplitude at 10 min (A10) of EXTEM was well correlated with Plt count and Fg levels (R(2)=0.46 and 0.52, respectively, P<0.0001). FIBTEM A10 was correlated with Fg (R(2)=0.55, P<0.0001). ROC analysis showed that EXTEM A10 with a threshold of 29 mm predicted thrombocytopenia with a sensitivity of 79% and a specificity of 60%, and a threshold of 26 mm predicted hypofibrinogenaemia with a sensitivity of 83% and a specificity of 75%. CONCLUSIONS: ROTEM is useful for the global assessment of coagulation in the operating theatre. EXTEM was the most informative for assessing the whole coagulation process and A10 showed value in guiding Plt and Fg transfusion.

[Phantom limb pain: from physiopathology to prevention]. / Douleur du membre fantôme : de la physiopathologie à la prévention.

First described in 1545, phantom limb pain is a frequent complication after limb amputation, described by 60 to 85% of amputees. Stump pain, phantom limb sensation and phantom limb pain are often combined. Physiopathology is complex and peripheral, medullar and cortical mechanisms are combined. Pharmacological preventive treatments as well as regional anaesthesia techniques have equivalent results. Such treatments must be investigated more precisely as postoperative rehabilitation of amputees mostly depends on pain relief.

[Thoracic epidural analgesia for a thrombocytopenic child]. / Analgésie péridurale thoracique chez un enfant thrombopénique.

Per- and postoperative analgesia of patients with chronic pain is a challenging issue for anaesthetists and can be achieved with locoregional anaesthesia, unless it is contraindicated. We report the case of a thrombocytopenic child presenting for thoracotomy and in whom intravenous analgesia failed after previous surgeries. Due to the central origin of the thrombocytopenia, thoracic epidural analgesia could be achieved, after platelet transfusions. When clinical advantage of thoracic epidural is unquestionable, central thrombocytopenia is a relative contraindication.

[Transfusion-related acute lung injury. A case report]. / Etiologie des oedèmes pulmonaires lésionnels transfusionnels. A propos d'un cas.

Acute lung injury is a common adverse effect of massive blood transfusion, responsible for 17% of the deaths due to transfusion in France. A cardiac origin is often suspected. We report a case of post-transfusional pulmonary oedema in a cirrhotic patient, which could be related to a non-cardiac and underdiagnosed aetiology: the so-called transfusion related acute lung injury (TRALI).