Use of rocuronium and sugammadex for video-assisted thoracoscopic surgery is associated with reduced duration of chest tube drainage: a propensity score-matched analysis.

BACKGROUND: We investigated the influence of different neuromuscular blocking agents and reversal agents during anaesthesia on early removal of chest tube drainage after video-assisted thoracoscopic surgery (VATS). METHODS: This retrospective single-centre study included patients who underwent VATS after tracheal intubation under general anaesthesia. Patients received either cisatracurium and neostigmine (n=547) or rocuronium and sugammadex (n=151). Quantitative neuromuscular monitoring was used and one chest tube (size 24 Fr) was inserted. To reduce potential bias, 140 patients from each group were matched by propensity score for sex, age, body mass index and indication for VATS. Primary outcome was duration of chest tube drainage after surgery. RESULTS: Use of rocuronium and sugammadex was associated with a shorter duration of chest tube drainage (2 [1-2] vs 2 [1-3] days; P=0.049) and a 63% reduction in delayed chest tube removal (odds ratio 0.37; 95% confidence interval [CI]: 0.20-0.67; P=0.005). This group also had a lower incidence of postoperative atelectasis (P=0.047) and consolidation (P=0.008). Each 1 h increase in the duration of anaesthesia was associated with a 1.57-fold increase in the delayed removal of the chest tube (95% CI: 1.25-1.96; P=0.005). CONCLUSIONS: During general anaesthesia for VATS, compared with cisatracurium and neostigmine, use of rocuronium and sugammadex was associated with a significant decrease in the incidence of postoperative delayed removal of the chest tube, atelectasis, and pulmonary consolidation.

Comparison of Glucose Loads and Blood Glucose Changes in Patients With and Without Diabetes Mellitus Undergoing Living Donor Liver Transplantation.

BACKGROUND AND PURPOSE: The purpose of this study was to identify the quantitative amount of glucose load, which maintained the blood glucose levels between 100 and 180 mg/dL in patients with and without diabetes mellitus (DM) undergoing living donor liver transplantation (LDLT). METHODS AND PATIENTS: The anesthesia records of 477 adult LDLT patients were reviewed retrospectively. The total amount of glucose loads and the changes in blood glucose between groups were compared by using Mann-Whitney U test. One-year patient survival between groups was compared with Pearson's χ2 test. A P value of <.05 was considered statistically significant. RESULTS: Eighty patients diagnosed with DM, who were all type II except one, were placed in group 1 (G1); and 397 patients without DM were placed in group 2 (G2). Table 1 shows that G1 received significantly less glucose loads in comparison to G2, but all the measured blood glucose levels, except in the reperfusion phase, were significantly higher in G1 than in G2. Both groups received glucose loads of 0.342 ± 0.191 and 0.774 ± 0.191 mg/kg/min for G1 and G2, respectively. No difference in 1-year survival between groups was observed. CONCLUSION: Patients with DM required significantly lower glucose loads compared to patients without DM.

Anesthetic Fluid Management of Patients With Hyponatremia Undergoing Living Donor Liver Transplantation.

OBJECTIVE: The objective of this study is to evaluate the changes in serum sodium levels in adult recipients with and without hyponatremia undergoing living donor liver transplantation (LDLT) without using hypertonic solution. METHODS: Patients were divided into 2 groups according to serum sodium level higher (GI) or lower (GII) than 130 mEq/L. The changes of serum sodium levels during an LDLT procedure and total sodium loads were compared between groups by using the Mann-Whitney U test, while the changes in the same group were paired by using the Student t test. A P value <.005 was considered significant. RESULTS: The total sodium load for GI (n = 438) and GII (n = 28) were 2737 ± 2159 mEq and 4017 ± 2830 mEq, respectively. Although GI received a significantly lower sodium load than GII, the serum sodium levels during the procedure were always within a normal range and higher than GII at all the measured time points; however, the changes of serum sodium level in GI from one point to the next measured point in the same group were unremarkable, while that of GII increased significantly between the 2 measured time points during the procedure. The mean total increase of serum sodium in GII was 5.57 ± 4.9 mEq/L in 14 hours of the LDLT procedure. None of the patients developed central pontine myelinosis (CPM) postoperatively. CONCLUSION: Patients with hyponatremia can be managed safely without using a hypertonic solution during liver transplantation. The mean increase of serum sodium of GII was of 5.57 ± 4.9 mEq/L, which was still within the acceptable and safe level. No postoperative CPM was observed in our GII patients.

Acute Kidney Injury in Adult Living Donor Liver Transplantation Performed with Different Methods of Inferior Vena Cava Clamping Maneuvers.

OBJECTIVE: The aim of this retrospective study is to evaluate and compare the incidence of acute kidney injury (AKI), defined as increase serum creatinine (SCr) of 0.3 mg/dl or increase in SCr to ≥1.5 times from baseline within 48 hour, in adult living donor liver transplantation patients performed with total cross clamp vs side clamp of the inferior vena cava (IVC). METHODS AND PATIENTS: Sixty adult living donor liver transplantation (LDLT) patients were divided into 2 groups: 30 patients in total IVC clamping (G1) and 30 in IVC side clamping (G2) during the anhepatic phase. Patients' characteristic, hemodynamic changes in percentage (%) as a result of different methods of IVC clamping, urine output during anhepatic phase were compared by using the Student t test, and the incidence of AKI were compared by using the χ2 test between groups. P value <.05 was regarded as significant. RESULTS: The negative impact of the 2 different ways of IVC clamping was significantly more severe in G1 compared to G2; consequently, the urine output of G1 was significantly less than G2. Although there was significantly more urine output of G2 during the anhepatic phase, the incidence of the postoperative AKI between groups was similar. CONCLUSION: The side clamp of the IVC had a significantly less negative impact on the hemodynamic parameters and provided sufficient urine output during the anhepatic phase (2.24 ± 3.17 vs 0.39 ± 0.33 mL/kg/h) compared to the total clamp of the IVC. But this favorable data did not protect the patient suffering from postoperative AKI in LDLT.

Clinical Beneficial Effects of Using Crystalloid only in Recipients of Living Donor Liver Transplantation.

OBJECTIVE: Liver transplantation (LT) is a major surgery associated with intraoperative massive fluid shift, which is usually replaced by crystalloid, 5% albumin (colloid) and blood products. We studied 15 patients from 477 consecutive recipients of adult living donor liver transplantation. Each patient received crystalloid only during LT. Whether LT provides any clinical benefit is not clear and must be determined. METHODS AND PATIENTS: The anesthesia records of 477 adult LDLT were reviewed retrospectively. The patients were divided into three groups according to the fluids received. Group I (GI) had received blood products, 5% albumin and crystalloid, group II (GII) received 5% albumin and crystalloid, and group III (GIII) received crystalloid only. The characteristic intraoperative variable and postoperative acute rejection and survival rate were compared amongst groups by using One Way ANOVA post hoc with Bonferroni and by Ficher's Exact test and Chi-square χ² test. RESULTS AND CONCLUSIONS: GIII had less intraoperative ascites and blood loss; they also had more stable hemodynamics. Furthermore, they could be extubated significantly earlier than GI, and the one- and three-year survival rates were excellent, with 100% in GIII, while that of GI and GII were 94.1%, 90.5% and 98.6%, 94.5%, respectively.

Effect and Outcome of Intraoperative Fluid Restriction in Living Liver Donor Hepatectomy.

BACKGROUND The purpose of this study was to evaluate the effect and outcome of intraoperative fluid restriction in living liver donor hepatectomy, regarding changes in intraoperative CVP levels, blood loss, and postoperative renal function. MATERIAL AND METHODS The charts of 167 patients were reviewed and analyzed retrospectively. Intraoperative central venous pressure levels, blood loss, fluids infused, and urine output per hour, before and after the liver allograft procurement, were calculated. Perioperative renal functions were also analyzed. RESULTS Fluid infused before and after liver allograft procurement was 3.21±1.5 and 9.0±3.9 mL/Kg/h and urine output was 1.5±0.7 and 1.8±1.4 mL/Kg/h, respectively. Intraoperative estimated blood loss was 91.3±78.9 mL. No patients required blood transfusion. Their preoperative and postoperative hemoglobin were 12.3±2.7 and 11.7±1.7 g/dL. CVP levels decreased gradually from 10.4±3.0 to a low of 8.1±1.9 mmHg at the time of transection of the liver parenchyma. Renal functions were not significantly affected based on the determination of BUN and creatinine levels. CONCLUSIONS The methods used to lower CVP are moderate and slow, with 2 main goals achieved: minimal blood loss (91.3±78.9 ml) and no blood transfusion. Furthermore, it did not have any negative effect on renal function.

Impact of Early Release of the IVC Clamp from Different IVC Clamping Maneuvers on Changes in Hemodynamic Parameters in Living Donor Liver Transplantation.

BACKGROUND The aim of this study was to evaluate the impact of different methods of inferior vena cava (IVC) clamping and release of the cross clamp on hemodynamic parameters of recipients during living donor liver transplantation. MATERIAL AND METHODS Ninety-six adult living donor liver transplantation patients were divided into 3 groups according to cross-clamp of the IVC for all the hepatic vein and portal vein reconstruction (G1), cross-clamp of the IVC only for hepatic vein reconstruction (G2), and side-clamp of the IVC for hepatic vein reconstruction (G3). In G2 and G2, the reconstructed hepatic vein was clamped instead of the IVC for portal vein reconstruction. The hemodynamic parameters among groups were compared by 1-way ANOVA and the complications in each group were compared using the Kruskal-Wallis test. RESULTS Changes in percentage of MAP and CO in G3 were significantly less than that of G1 and G2 for hepatic vein reconstruction. Hemodynamic parameters of G2 and G3 normalized to pre-clamped values during portal vein reconstruction, while the hemodynamics of G1 remained unstable. CONCLUSIONS Hemodynamic changes were less pronounced in LT with side-clamp of the inferior cava vein versus total cross-clamp. Early release of the IVC clamp minimized the hemodynamic changes. There were no differences in terms of outcome (morbidity and mortality).

Living donor liver transplantation with body-weight more or less than 10 kilograms.

AIM: To compare the outcomes of pediatric patients weighing less than or more than 10 kg who underwent liver transplantation. METHODS: Data for 196 pediatric patients who underwent living donor liver transplantation between June 1994 and February 2011 were reviewed retrospectively. The information for each patient was anonymized and de-identified before analysis. The data included information regarding the pre-transplant conditions, intraoperative fluid replacement and outcomes for each patient. The 196 patients were divided into two groups: those with body weights of less than 10 kg were included in group 1 (G1; n = 101), while those with body weights of more than 10 kg were included in group 2 (G2; n = 95). For each group, the patients' ages, body weights, heights, pediatric end stage liver disease scores, anesthesia times, and warm and cold ischemic times were analyzed. In addition, between-group comparisons were also made. Mann-Whitney U tests were used to compare all the variables except for complications and survival rates, which were analyzed using χ(2) tests and Kaplan-Meier tests, respectively. RESULTS: The general medical conditions of the G1 patients were worse than those of the G2 patients, as shown by the higher pediatric end stage liver disease scores and poorer Z-scores. In addition, the pre-operative Hb and serum albumin levels were all lower for the G1 patients than for the G2 patients. The G1 patients also had significantly more intraoperative blood loss than the G2 patients. In addition, the intraoperative fluid requirements for the G1 patients, including leukocyte poor red blood cell transfusions, 5% albumin infusions and crystalloid infusions, were significantly higher than those for the G2 patients. The risk of intraoperative portal vein thrombosis was higher for the patients in G1 than for those in G2. However, the one-year survival rates (95.9% and 96.8% for G1 and G2, respectively) and three-year survival rates (94.9% and 94.6% for G1 and G2, respectively) for both groups were similar. CONCLUSION: Patients weighing less than 10 kg typically have poorer conditions, but their survival rates are comparable to those of children weighing more than 10 kg.

The effectiveness of prophylactic attachment of adhesive defibrillation pads in adult living donor liver transplantation.

BACKGROUND: The aim of current study is to present the effectiveness of prophylactic attachment of adhesive defibrillation electrode pads in adult living donor liver transplantation. MATERIAL AND METHODS: We divided 487 adult living donor liver transplantation patients into 2 Eras according to the history of without (Era 1) and with (Era 2) pre-attachment of adhesive defibrillation pads. The incidences of intraoperative cardiac events requiring cardioversion or defibrillation, its management, and outcome between Era 1 and 2 were compared. RESULTS: Two cases out of 124 patients (1.6%) in Era 1 had cardiac arrest. The closed chest cardiac massage in 1 cardiac arrest in Era 1 required trans-diaphragmatic open-chest cardiac massage followed by internal cardiac defibrillation due to difficulty in performing external defibrillation. Both patients of Era 1 had in-hospital mortality. Four patients of Era 2 (n=363) received electrical treatment (1.01%); 2 had paroxysmal tachycardia requiring cardio-version and the other 2 had ventricular fibrillation requiring closed-chest cardiac massage and external defibrillation. All 4 patients in Era 2 regained sinus rhythm after electrical treatment, tolerated the subsequent operation well, and had 100% survival to date. CONCLUSIONS: Our results show that prophylactic attachment of adhesive defibrillation pads allows the immediate performance of cardioversion, conventional closed-chest CPR, and defibrillation if indicated without any delay and without interference with the sterility of the operation field. Our preliminary result is clear and encouraging.

Review of anesthesia in liver transplantation.

Liver transplantation (LT) is a well-accepted treatment modality of many end-stage liver diseases. The main issue in LT is the shortage of deceased donors to accommodate the needs of patients waiting for such transplants. Live donors have tremendously increased the pool of available liver grafts, especially in countries where deceased donors are not common. The main ethical concern of this procedure is the safety of healthy donors, who undergo a major abdominal surgery not for their own health, but to help cure others. The first part of the review concentrates on live donor selection, preanesthetic evaluation, and intraoperative anesthetic care for living liver donors. The second part reviews patient evaluation, intraoperative anesthesia monitoring, and fluid management of the recipient. This review provides up-to-date information to help improve the quality of anesthesia, and contribute to the success of LT and increase the long-term survival of the recipients.

Acquired hyponatremia in pediatric living donor liver transplantation.

BACKGROUND: The aim of this study was to evaluate the incidence of acquired hyponatremia (AH) in our pediatric living donor liver transplantation (LDLT) patients, and to identify the potential predictive risk factors of the causes of AH. MATERIAL/METHODS: The 189 pediatric LDLT patients were divided into 2 groups: serum sodium level at the end of the surgery lower than 130 mEq/L in GI (n=16) and higher than 130 mEq/L in GII (n=173). Patients' data were analyzed by Mann-Whitney U test, univariate analysis, and multiple binary logistic regression model. The Hosmer-Lemeshow goodness-of-fit test was used to evaluate the logistic model formulated. P value <0.05 was regarded as statistically significant. RESULTS: In the multiple binary logistic regression model, the hypotonic solution administration rate (ml/kg/h) was the only independent predictor of AH with a p<0.017. Receiver operating curve (ROC) analysis indicated that giving more than 3.5 ml/kg/h hypotonic solution infusion may cause AH. Preoperative hyponatremia did not increase the incidence of acquired hyponatremia. CONCLUSIONS: Increasing the administration of hypotonic solution by 1 ml/kg/h in pediatric LDLT would increase the risk of developing AH by 1.272 times. The critical administration rate of hypotonic solution was 3.5 ml/kg/h.

Should abnormal coagulation data found in thromboelastography be corrected during liver transplantation? Experience of two cases.

Coagulopathy is common in patients with end-stage liver disease requiring liver transplantation (LT). Thromboelastography (TEG) test results are used for analyzing coagulation data and making a decision about the transfusion requirements. However, whether it is necessary to correct the abnormal coagulation profile during LT is a matter of considerable debate. Herein, we report our experience with two patients who had LT without blood product transfusion despite TEG results showing abnormal coagulation data. The TEG was performed four times during LT. Although blood product transfusion was necessary according to the TEG guidelines, it was avoided. At the end of operation, the hemoglobin level was 8.5 g/dL and 9.5 g/dL for Patient 1 and Patient 2, respectively. The patients tolerated LT well and their subsequent recovery was uneventful. We suggest that TEG should be used cautiously to make a decision about blood transfusion, as it can be totally avoided in selected cases involving living donor LT.

Predictive factors for pediatric patients requiring massive blood transfusion during living donor liver transplantation.

BACKGROUND: The aim of this study was to identify the preoperative risk factors that may predict the requirement of massive blood transfusion during pediatric living donor liver transplantation. MATERIAL AND METHODS: The anesthesia charts of pediatric patients undergoing living donor liver transplantation were reviewed retrospectively. Patients were grouped into 2 categories based on the amount of intraoperative blood transfusion. Group I (GI) consists of patients who received massive blood transfusion and Group II (GII) consists of patients who did not receive massive blood transfusion. The patients' characteristics and preoperative data were compared between groups with the Mann-Whitney U test. Predictive risk factors for massive blood transfusion were analyzed by binary regression. A p value of <0.05 was regarded as significant. Data are given as mean ±SD. RESULTS: A total of 198 pediatric patients were included in this study. Thirteen (6.5%) of the 198 pediatric patients undergoing living donor liver transplantation met the criteria of massive blood transfusion. The mean estimated blood volume of GI and GII was 724±322 and 1097±830 ml, respectively. The mean quantity of blood products given were 1018±591 and 187±220 ml for GI and GII, respectively. RBC was given to 67% of the patients, FFP was given to 18%, and only 1% received platelet transfusion. The patients who required massive blood transfusion were younger in age and had smaller body size, with prolonged INR (international normalized ratio) observed. INR, a measure of blood clotting time, was the only predictive factor that can impact intraoperative massive blood loss and subsequent blood transfusion. Each prolongation of 0.1 unit of INR elevates by 1.083-fold the risk of massive blood transfusion (95% C.I.=1.030-1.139, P=0.002). CONCLUSIONS: Preoperative INR was the only predictive risk factor for massive blood transfusion during pediatric living donor liver transplantation. Increasing the ratio of FFP transfusion in patients with prolonged INR before or during pediatric LDLT is recommended.

Predictive factors associated with re-exploration for hemostasis in living donor liver transplantation.

BACKGROUND: After liver transplantation (LT), re-exploration of the abdomen to check for bleeding is sometime required. Our study aimed to identify the predictive factors by analysis of preoperative and intraoperative presentations that may impact the re-exploration for hemostasis. MATERIAL/METHODS: We selected 522 consecutive recipients from the Liver Transplant Program database and medical records between January 1, 1994 and December 1, 2009 in our hospital. Demographic data (age, sex, body mass index, weight, MELD score), preoperative laboratory tests (Hb, platelet, albumin, bilirubin, INR, APTT), and intraoperative presentations (ascites and blood loss, crystalloids, 5% albumin infused, blood products used (such as LPRBC, RBC, FFP, platelet, cryoprecipitate), urine output, Hb at end of operation, and anesthesia) were collected for primary comparison. Potential predictors found by univariate comparison at p<0.1 were put into a multiple binary logistic regression model. RESULTS: Thirty-eight (7.3%) recipients required re-exploration for hemostasis after LDLT; 80% needed re-exploration only once. In univariate analysis, recipients transfused with FFP >10 ml/kg had a 4.2-fold increased risk of re-exploration (p<0.001). Thirteen potential predictors by univariate comparison at p<0.1 were selected into a multiple binary logistic regression. Fresh frozen plasma (FFP) transfused was the sole predictor. CONCLUSIONS: Each elevation of 1ml of transfused FFP per kg is associated with a 1.033-fold increased incidence of re-exploration for hemostasis. Patients transfused with more than 10 ml/kg FFP during LT require more intensive management within 72 hours due to increase risk of postoperative bleeding.

Intraoperative blood and fluid administration differences in primary liver transplantation versus liver retransplantation.

OBJECTIVES: Liver retransplantation (Re-LT) is the effective therapy for irreversible liver graft failure after primary liver transplantation (LT). The challenges faced by the operative team in the Re-LT setting have been seldom elucidated. Our aim is to analyze the differences in fluid management in primary LT and Re-LT during the surgical procedure. METHODS: The anesthesia charts of 16 patients who underwent both primary LT and Re-LT at our center in the space from October 1995 to May 2009 were analyzed. Group 1 (GI) consisted of patients who underwent primary LT, whereas patients in Group 2 (GII) were patients in GI but underwent Re-LT. GI was further divided into two subgroups depending on whether they had previous abdominal surgery before primary LT (GIB) or not (GIA). Wilcoxon signed-ranks test was used to compare GI and GII, and GIA and GIB. A p value less than 0.05 was regarded as significant. Data were given as mean ± standard deviation. RESULTS: Blood loss was significantly increased from 48.9 ± 106 mL/kg in GI to 251.5 ± 242 mL/kg in GII. Consequently more blood products, crystalloids, sodium bicarbonate, calcium chloride, and neosynephrine were required to support the hemodynamics in GII. In GI, GIB tended to bleed more and required more blood transfusions than GIA. CONCLUSION: More bleeding is expected in Re-LT than primary LT. Additional anesthetic personnel, more intravenous lines, and blood and blood products should be readily available to deal with the emergent fluid and hemodynamic resuscitations in anesthesia for Re-LT.

Two cases of massive pleural effusion noted only after induction of anesthesia in living donor liver transplantation.

Two adult patients who underwent living donor liver transplantation with acute accumulation of right-side pleural effusion are reported. The chest X-ray of patient 1 showed no specific finding 3 days before the operation, and patient 2 was known to have pleural effusion and underwent pigtail drainage before transplant. After anesthesia induction and insertion of central venous catheters, a portable chest radiograph was taken to confirm the positions of the central venous catheters and endotracheal tube. A massive right-side pleural effusion was noted unexpectedly in both patients. Approximately 2,000 ml transudative fluid was surgically drained through the right diaphragm in patient 1 upon opening of the abdominal cavity. The acute accumulation of massive pleural fluid in patient 2 was caused by clamping of the pigtail drainage tube during patient transfer to the operating room; upon unclamping of the tube, 2,000 ml fluid was drained. The intraoperative and postoperative transplant courses of both patients were uneventful. Both were discharged from the hospital in stable condition. Our cases suggest that chest X-ray after induction of the anesthesia and before liver transplantation surgery is recommended. In addition to documenting the positions of the central venous catheters and endotracheal tube, a potential life-threatening pleural effusion requiring appropriate management may be detected.

The method and accuracy of documentation of intraoperative fluids management in liver transplantation recipients.

BACKGROUND: In liver transplantation, blood loss can be massive, requiring timely and rapid fluid resuscitation. Maintaining proper documentation of fluids during such situations can be difficult and may often lead to counting errors. We report our method of documentation of fluid management during liver transplantation. MATERIAL/METHODS: Each unit of red blood cells (125 cc) that comes from the blood bank had a serial number of 10 Arabic numbers which were verified and double-checked. Each unit was then numbered and labeled as encircled absolute numbers (e.g., 1, 2, 3). Both the encircled number and the serial number of the bag were recorded in the anesthesia chart. Each liter of crystalloids and colloids were similarly numbered and labeled in sequence for ease of calculation. At the end of the operation, the nurse anesthetist ascertains that the number of units of blood products used matched with the number of units supplied by the blood bank. The total amounts of crystalloids and colloids given during the operation was also calculated, rechecked and written in a tabulated form. RESULTS: Since the introduction of this method, we have detected and readily corrected 3 incidences of counting discrepancy in the total units of blood products transfused and the products supplied by the blood bank. Moreover, our records have now become transparent data that are easily retrievable for future scientific research. CONCLUSIONS: Our method of documentation of fluid management during liver transplantation is easy, accurate and effective.

Serum factors potentiate hypoxia-induced hepatotoxicity in vitro through increasing transforming growth factor-beta1 activation and release.

BACKGROUND: Although transforming growth factor-beta (TGF-beta), a growth regulator of hepatocytes, induces cell death under pathological conditions, responsiveness of hepatocytes to hypoxic stimulus has not been fully defined. This study aimed at investigating the role of TGF-beta1 in hypoxia-induced hepatotoxicity using cultured clone-9 hepatocytes with or without serum supplementation. METHODS/RESULTS: Presence of serum significantly potentiated hypoxia-induced hepatotoxicity after 72h of exposure, as evidenced by fluorescent viability stain and LDH cytotoxicity assay. Quantitative PCR showed that TGF-beta1 gene expression decreased, while ELISA revealed that latent TGF-beta1 in conditioned media prominently increased in serum-treated groups under hypoxia. Western blotting indicated that both type I and II receptors of TGF-beta were up-regulated in serum-free groups, but down-regulated in serum-treated groups under hypoxia. Smad2 phosphorylation was only detectable in cells supplemented with serum, and hypoxia potentiated the extent of Smad2 phosphorylation, implicating that the activated TGF-beta1 induces hepatotoxicity in an autocrine manner. Addition of exogenous TGF-beta1 deteriorated, while TGF-beta1 blockade by neutralizing antibody ameliorated hypoxia-induced hepatotoxicity with serum supplementation. Gelatine zymography and immunofluorescent stain evidenced that elevated MMP-2 and MMP-9 activity and serum-dependent CD44 expression and its membranous localization may contribute to TGF-beta1 activation. CONCLUSION: The results suggest that the mechanism governing TGF-beta activation plays a crucial role in hypoxia-induced hepatotoxicity. Thus, interventions on TGF-beta1 bioavailability and/or its cognate signaling may be of benefit in preventing hypoxia-related liver injuries.

Propofol pretreatment attenuates LPS-induced granulocyte-macrophage colony-stimulating factor production in cultured hepatocytes by suppressing MAPK/ERK activity and NF-kappaB translocation.

Propofol (PPF), a widely used intravenous anesthetic for induction and maintenance of anesthesia during surgeries, was found to possess suppressive effect on host immunity. This study aimed at investigating whether PPF plays a modulatory role in the lipopolysaccharide (LPS)-induced inflammatory cytokine expression in a cell line of rat hepatocytes. Morphological observation and viability assay showed that PPF exhibits no cytotoxicity at concentrations up to 300 microM after 48 h incubation. Pretreatment with 100 microM PPF for 24 h prior to LPS stimulation was performed to investigate the modulatory effect on LPS-induced inflammatory gene production. The results of semi-quantitative RT-PCR demonstrated that PPF pretreatment significantly suppressed the LPS-induced toll-like receptor (TLR)-4, CD14, tumor necrosis factor (TNF)-alpha, and granulocyte-macrophage colony-stimulating factor (GM-CSF) gene expression. Western blotting analysis showed that PPF pretreatment potentiated the LPS-induced TLR-4 downregulation. Flow cytometrical analysis revealed that PPF pretreatment showed no modulatory effect on the LPS-upregulated CD14 expression on hepatocytes. In addition, PPF pretreatment attenuated the phosphorylation of mitogen-activated protein kinase/extracellular signal-regulated kinase (MAPK/ERK) and IkappaBalpha, as well as the nuclear translocation of NF-kappaB primed by LPS. Moreover, addition of PD98059, a MAPK kinase inhibitor, significantly suppressed the LPS-induced NF-kappaB nuclear translocation and GM-CSF production, suggesting that the PPF-attenuated GM-CSF production in hepatocytes may be attributed to its suppressive effect on MAPK/ERK signaling pathway. In conclusion, PPF as an anesthetic may clinically benefit those patients who are vulnerable to sepsis by alleviating sepsis-related inflammatory response in livers.

Perforation of the right ventricle by a pulmonary artery catheter that continues to measure cardiac output and mixed venous saturation.

During urgent cardiopulmonary bypass for acute myocardial infarction, a pulmonary artery (PA) catheter was inserted in an 81-year-old male patient for monitoring of cardiopulmonary function. The presence of the PA catheter in the right pericardium was noted by the cardiothoracic surgeon during surgery. In retrospect, the malposition of the catheter in the pericardium could be clearly seen in the routine intraoperative transesophageal echocardiogram. The presence of a PA pressure waveform and the ability to measure cardiac output and mixed venous oxygen saturation from the PA catheter does not exclude the possibility that it could still be perforating the right ventricle.