Anesthesia-related complications in living liver donors: the experience from one center and the reporting of one death.

Living donor liver transplantation has become an alternative therapy for patients with end-stage liver disease. Donors are healthy individuals and donor safety is the primary concern. The objective of this study was to evaluate the anesthetic complications and outcomes for our donor cases; we report one death. The charts of the patients who underwent donor hepatectomy from February 1997 to June 2007 were retrospectively reviewed. Right hepatectomy (resection of segments 5-8) was done in 101 donors, left lobectomy (resection of segments 2-3) in 11 donors, and left hepatectomy (resection of segments 2-4) in one donor. Minor anesthetic complications were shoulder pain, pruritus and urinary retention related to epidural morphine, and major morbidity included central venous catheter-induced thrombosis of the brachial and subclavian vein, neuropraxia, foot drop and prolonged postdural puncture headache. One of 113 donors died from pulmonary embolism on the 11th postoperative day. This procedure has some major risks related to anesthesia and surgery. Although careful attention will lower complication rate, we have to keep in mind that the risks of donor surgery will not be completely eliminated.

Comparison of effects of preoperatively administered lornoxicam and tenoxicam on morphine consumption after laparoscopic cholecystectomy.

BACKGROUND AND OBJECTIVE: The efficacy, tolerability and the morphine-sparing effects of lornoxicam were compared with those of tenoxicam when used preoperatively in patients undergoing laparoscopic cholecystectomy. METHODS: In this prospective, double-blind study, 60 ASA I-II patients undergoing laparoscopic cholecystectomy were randomized equally to receive intravenous tenoxicam 40 mg (Group T) or lornoxicam 16 mg (Group L), preemptively. Three patients withdrew from the study, so 57 patients were included in the analysis. In the postoperative period, the first morphine demand times, pain scores, side-effects and cumulative morphine consumptions were evaluated during the first 24 h. RESULTS: The patient characteristics data and the duration of surgery were similar between two groups, except for body weights (P = 0.002). The first morphine demand time was significantly longer in Group L (P = 0.037), but the pain levels did not differ. The mean pain scores were higher in Group T in the 15 min (P = 0.036), 1 h (P = 0.020), 2 h (P = 0.001) and 4 h (P = 0.0042) after extubation. A statistically significant difference between two groups was found in calculated cumulative morphine consumptions per kilogram in the 15 min (P = 0.037), 30 min (P = 0.016), and 1 h (P = 0.004) and 2 h (P = 0.013) between two groups. There was no difference in the severity of nausea but 13 patients in Group T and five patients in Group L had vomiting (P = 0.018). Patient satisfaction was similar in the two groups. CONCLUSIONS: Preoperatively administered lornoxicam 16 mg significantly prolonged the first morphine demand time, reduced postoperative morphine consumption during the first 4 h and caused significantly fewer adverse effects when compared with tenoxicam after laparoscopic cholecystectomy.

Efficacy of right anterior sector drainage reconstruction in right-lobe live-donor transplantation.

BACKGROUND: Without including the middle hepatic vein (MHV) into right-lobe grafts, venous drainage of the anterior segment (AS) has always been a concern. The efficacy and the necessity of additional venous reconstruction in the AS for graft viability and function are still controversial. METHODS: Since February 2002, 57 right-lobe grafts were implanted into adult recipients. The mean graft to ideal recipient weight ratio (GRWR) was 1.3% (minimum: 0.8%, maximum 2.1%). All minor venous tributaries to the MHV less than 5 mm in diameter were ligated. The management of MHV tributaries was categorized into three groups: (A) no major tributaries (n = 33); (B) major tributaries ligated (n = 11); and (C) major tributaries reconstructed (n = 13). Reconstructions were established using vascular grafts (PTF, n = 8; cadaveric, n = 2) or joining with right hepatic vein orifice (n = 6). The groups were homogenous in age, gender, MELD (17 +/- 6, 16 +/- 4, 18 +/- 7), graft weight (817 +/- 181, 838 +/- 152, and 855 +/- 159 g), and graft/ideal liver weight ratio (0.54 +/- 0.12, 0.57 +/- 0.13, and 0.57 +/- 0.1, respectively). We investigated the volume of ascites, serum bilirubin, albumin, and liver enzyme levels and INR on postoperative day 4 (POD4) and POD21. RESULTS: Two patients died of MRSA sepsis on POD18 and POD23 (MELD: 24 and 28) after initial graft function. Their graft weights were 800 g and 980 g, and their volumes were 47% (group B) and 62% (group A) of the ideal liver mass of the recipients, respectively. One PTF and another cadaveric vascular graft were found occluded 4 and 7 days after implantation without any negative consequence. At 6-month follow-up, the remaining 55 patients were alive with primary liver grafts. Vascular reconstructions were patent except for 2 early occlusions. Among the 3 groups, no significant difference was found on POD4. Three weeks after transplantation, the mean AST level in the major ligation group (46.7 +/- 8.14) was significantly higher than in the minor ligatation group (29.6 +/- 8.6) but not in the major reconstruction group (33.7 +/- 3.7; P = .03 and P = .29). The mean albumin level was highest after minor ligation (3.2 +/- 0.18), which was significantly better than the major reconstruction (2.7 +/- 0.1) but not the major ligation (3.1 +/- 0.14) cohorts (P = .02 and P = .13). CONCLUSIONS: In this study of a limited number of cases, right-lobe liver grafts with GRWR of > or =1.1% displayed optimal graft function without additional venous reconstruction to the AS.

Prophylactic use of low-dose, on-demand, intramuscular hepatitis B immunoglobulin and lamivudine after liver transplantation.

The combination of hepatitis B immunoglobulin (HBIG) and antivirals (nucleos[t]ide analogs) has extended the applicability of orthotopic liver transplantation (OLT) for patients with hepatitis B virus (HBV)-related liver disease. However, HBIG administrations have an extremely high cost. Herein, we evaluated our results with low-dose, on-demand, intramuscular HBIG plus lamivudine (LAM) prophylaxis after OLT. The HBV DNA status in 40 patients at the time of OLT determined the treatment: group A (n = 22), HBV DNA (-), no antiviral pretreatment; group B (n = 11), HBV DNA (-), after LAM; group C (n = 3), HBV DNA (+) after LAM (LAM resistance/Adefovir [ADV] unavailable); group D (n = 2), HBV DNA (+), no antiviral pretreatment; and group E (n = 2), HBV DNA (-) after LAM + ADV (LAM resistance/ADV available). Five patients died within 12 months after OLT unrelated to HBV infection. The remaining 35 patients were followed for a median duration of 16 months (range, 6-93 months). Only two recipients from group C, who were transplanted despite LAM resistance + no ADV pretreatment, revealed recurrent HBV infections at 14 and 16 months posttransplantation; they were then treated successfully with ADV as it became available. The third group C recipient had undetectable HBV DNA at 18 months after OLT. The mean cumulative doses of HBIG administered within the first, second, and third years were 34,014, 5258, and 5090 IU, respectively. In conclusion, low-dose, on-demand, intramuscular HBIG plus (LAM +/- ADV) prophylaxis is a safe, efficient, and cost-effective regimen to prevent recurrent HBV infection following OLT. OLT despite untreated LAM resistance may require sustained higher serum HBsAb levels after surgery.

Comparison of the haemodynamic effects of interscalene block combined with general anaesthesia and interscalene block alone for shoulder surgery.

Interscalene brachial plexus block (ISB) anaesthesia is widely used with or without general anaesthesia in patients undergoing shoulder surgery, which is generally done with the patient in a sitting position. This position affects haemodynamics, and supplementing ISB with general anaesthesia can exaggerate these haemodynamic changes. This study compared ISB combined with general anaesthesia, with ISB alone, in 29 patients undergoing elective shoulder surgery. Heart rate and oxygen saturation remained stable throughout the study in both groups. Mean arterial pressure was significantly decreased when the patient moved into the sitting position in those given combined anaesthesia, whereas in those given ISB alone mean arterial pressure did not change significantly. Neither pain scores nor patient satisfaction scores differed significantly between the two groups. All of the patients were either satisfied or entirely satisfied with their anaesthesia/analgesia. There were no significant differences in side-effects and no severe complications in either group. We advocate using ISB alone for patients undergoing shoulder surgery, but further larger studies are needed to confirm the present results.

Comparison of the antiemetic efficacy of tropisetron and droperidol with patient-given tramadol.

We compared the antiemetic efficacy of tropisetron versus droperidol in women given tramadol after total hysterectomy. Forty patients were randomly allocated to group 1 (n = 20, tropisetron 0.05 mg/kg intravenously) or group 2 (n = 20, droperidol 15 micrograms/kg intravenously). Tramadol infusion (intravenously), for post-operative analgesia, was started at fascia closure. Incidences of post-operative nausea and vomiting, pain intensity, tramadol use, and the need for a rescue antiemetic (metoclopramide 10 mg) were recorded 0 h, 2 h, 6 h, 12 h, 24 h and 48 h post-operatively. Vomiting and nausea incidences were reported fewer in group 1 than in group 2, but statistical significance was only reached for vomiting incidence 6 h post-operation. Tropisetron seems to have better antiemetic properties than droperidol in patients receiving tramadol because of the length of its duration of action. Further studies, investigating alternative ways of managing post-operative nausea and vomiting, and the use of tramadol for post-operative analgesia, are needed.

The effects of propofol on normal and hypercholesterolemic isolated rabbit heart.

The aim of the present study was to compare the effects of propofol on cardiac contractile force in normal and hypercholesterolemic isolated rabbit hearts. While one group was fed with standard chow pellets (150 g/day), the other group received cholesterol (1% w/w) in addition to the same amount of rabbit chow pellets during 1 month. Hearts from standard-fed rabbits were given intralipid solvent or 25, 50 and 100 microM propofol by infusion. Hypercholesterolemic rabbit hearts were administered 25, 50 and 100 microM propofol by infusion. All concentrations of propofol did not result in any significant change of the heart rates (HR) in two groups. Propofol (25, 50 and 100 microM) infusion induced a concentration- and time-dependent inhibition in left ventricular pressure (LVP) in standard chow diet group (P<.05,.05 and.05, respectively). In hypercholesterolemic rabbit hearts, 25 and 50 microM propofol infusion developed a significant inhibition in LVP when compared with the standard chow diet group (P<.05 and.05, respectively). Propofol (100 microM) infusion developed a significant increase in LVP after 20 min in hypercholesterolemic rabbit hearts when compared with normal rabbit hearts (P<.05). Supratherapeutic concentration of propofol might have cardioprotective effect on hypercholesterolemic rabbit hearts.

The effect of cerebral palsy on the action of vecuronium with or without anticonvulsants.

Patients with cerebral palsy who are treated with anticonvulsant medication are resistant to vecuronium. We examined the contributions to vecuronium resistance made by cerebral palsy and anticonvulsants in a study of children with cerebral palsy and a control group. The acceleromyographic responses of the following three groups of children were studied: children with cerebral palsy not taking anticonvulsant medication (n = 11); children with cerebral palsy taking anticonvulsant medication (n = 8); and a control group of children who did not have cerebral palsy and were not taking anticonvulsant treatment (n = 10). Using a standardised technique, general anaesthesia was induced and maintained with 0.5-1. 5% isoflurane in a 60/40 nitrous oxide in oxygen mixture. After a stabilisation period which was performed with supramaximal train-of-four stimuli (2 Hz every 15 s) an intubating dose of vecuronium 0.1 mgkg-1 was administered. The first twitch of the train-of-four response (T1), the onset time, the times to 25, 50, 75 and 90% recovery of T1, recovery index, and the time to 70% recovery of train-of-four ratio were recorded. Recovery times to T1 and train-of-four responses were reduced significantly in both groups of children with cerebral palsy compared with the control group. These results suggest that children with cerebral palsy display resistance to vecuronium whether or not they are taking anticonvulsant drugs.