Mapping nursing interventions using the Therapeutic Intervention Scoring System in bloodless liver transplantations.

BACKGROUND: The Simplified Therapeutic Intervention Scoring System adapted to liver transplantation by King's College Hospital rank 138 activities to determine the nursing workload, diagnostic, monitoring and therapeutic needs. OBJECTIVES: To evaluate nursing activities of "King's-TISS" score grouped in organ systems and nurse patient ratio in the perioperative 48 hours of blood product free liver transplantations (LT). METHODS: The "King's-TISS" score's were analysed by nursing procedures and grouped, scored according to organ systems. The nursing workloads were studied during LT (T1), on arrival on the ICU (T2) and 12-24-48 hours after LT (T3-T4-T5). RESULTS: The total of "King's-TISS" score points were decreased by ≥20% daily (p = 0.001). The mean score of 104 ± 3.5 points (CI:104-105) during LT decreased to 84.7 ± 12 points (CI:83-86) in 48 hours (T5). The "metabolic" and "haemostasis" points increased (p = ).01), the "immunology" points unchanged (T2-T5) postoperatively. A slight decrease was observed in case of "basic nursing care", "monitoring", "neurologic support", "renal support" and "cardiovascular support" points (T2-T5, p < .01). The "invasive intervention" and "ventilatory support" points strongly decreased (T2-T5, p < .001). One "King's-TISS" point was found to equal 7.4 minutes with a nurse patient ratio of 2:1 intraoperatively and 1:1 postoperatively. CONCLUSION: Absence of blood product administration in LT decreases the total and organ specific workload, except the metabolic, haemostasis, immunology and basic support requirement. It was not within the scope of the King's-TISS score to analyse the application of viscoelastic haemostasis test and coagulation factor concentrate administration.

How Much Is the Inevitable Loss of Different Coagulation Factors During Blood Product-Free Liver Transplantations?

BACKGROUND: Bloodless liver transplantations (LT) have already been reported, but special characteristics of hemostatic changes remain less defined. The aim of this study was to evaluate the "inevitable" loss of coagulation factors (CF) in blood product-free LT. METHODS: Blood product and CF concentrate-free LT patient data were analyzed in terms of the first 2 days of perioperative hemostasis kinetics (N = 59). CF levels (FI, II, V, VII, X, and XIII), platelet (PLT) levels, and hemoglobin levels were measured before LT (T1), on arrival at the intensive care unit (T2), and 12, 24, and 48 hours after LT (T3, T4, and T5, respectively). Thromboelastographic (TEG) parameters were determined before and at the end of LT (T1-T2). RESULTS: Fibrinogen levels decreased by 1.2 ± 0.6 g/L, prothrombin levels by 26% ± 14%, factor V levels by 40% ± 23%, VII levels by 29% ± 19%, and X levels by 39% ± 22% (P < .001). From T2 to T4 fibrinogen increased by 0.9 ± 0.6g/L for 24 hours (P < .001). Factor II, V, and VII levels increased by 20% ± 16%, 31% ± 32%, and 12% ± 27%, respectively, between T3 and T5 (P < .001). However, factor X reached only half of the T1 level (T3-T5, P < .001). Platelet count increased in 34 (58%) patients at T2 (P < .001). The TEG parameters remained in the normal range during LT (T1-T2). CONCLUSION: The major findings of this study advocate that "inevitable" levels of CF decrease during LT by an average of 1.2 g/L in terms of fibrinogen and 23% to 40% regarding factors II, V, VII, and X. The authors suggest that knowing the "magic numbers" and comparing them against baseline laboratory results might predict the possibility of blood product-free transplant, providing confidence and safety to the surgeon and the anesthetist.

Systolic Blood Pressure Pattern: The Tick Mark Signal of Delayed Renal Graft Function.

BACKGROUND: Delayed graft function (DGF) is a multifactorial clinical entity. The aim of our study was to analyze the role of perioperative fluid and noninvasive hemodynamic parameters in DGF patients. METHODS: The medical records of 122 adult deceased donor kidney transplant patients were retrospectively analyzed with respect to donor (medical history, kidney donor risk index), recipient (medical history), transplant (cold-warm ischemia time, renal arterial resistive index), and perioperative anesthetic, especially noninvasive hemodynamic management. Patients were grouped as DGF and immediate graft function. RESULTS: Prevalence of DGF was 21.3% (n = 26). Delayed graft function was related to higher donor body mass index (P = .04), kidney donor risk index higher than 1.6 (P = .008), recipient age older than 65 years (P = .03), and perioperative factors, such as lower residual diuresis of recipient (8.7 [SD, 5.2] mL/kg vs 14.4 [SD, 10.3] mL/kg; P = .005), higher intradialytic weight gain (2.65 [SD, 1.03] kg vs 2.16 [SD, 0.79] kg; P = .07), and higher fluid balance during the first postoperative day (3310 [SD, 1230] mL vs 2354 [1812] mL; P = .01). The curve of change in systolic blood pressure (SBP) showed a tick mark pattern in DGF and a semicircular shape in the immediate graft function group. In the DGF group, SBP change compared with baseline value was higher at reperfusion (-3.16% [SD, 23.37%] vs -12.84% [SD, 23.37%]; P = .047), at the ending of surgery (-5.83% [SD, 26.21%] vs -3.26% [SD, 21.81%]; P = .07), and at the ending of anesthesia (11.81% [SD, 29.77%] vs -1.26% [SD, 21.87%]; P = .01). The postoperative renal arterial resistive index was higher in the DGF group (0.75 [SD, 0.10] vs 0.69 [SD, 0.08]; P = .007). CONCLUSION: The tick mark pattern of SBP kinetics might help to identify DGF intraoperatively. When detecting this SBP pattern, the excessive fluid therapy should be avoided during the postoperative period to prevent iatrogenic hypervolemia leading to further graft damage.

Practices Around Communication About Organ Donation in Hungary.

BACKGROUND: One obstacle to organ donation is the high proportion of relatives who refuse consent in presumed-consent countries. The aim of this study was to survey the features of family approaches and to identify those that may have significant impact on family refusals. METHODS: A 46-item validated questionnaire was designed and used in 2011 and 2012 to investigate factors around all family communications about brain death and organ donation. The data of 188 cases were collected by telephone calls. We asked for the demographic data of donors; place, timing, duration, type, and result of approach; number, age, gender, and qualification of the staff; affinity, gender, age, education, and religion of the involved relatives; and finally the applied method to treat family refusal if it existed. RESULTS: Usually 1 physician talked with 2 relatives. Timing had significant impact on objection rate (χ2 = 0.044). Single-discussion meetings (56.38%) were an average 1 hour 13 minutes before the brain death declaration, and they were initiated an average 19 hours 49 minutes before brain death when more than one meeting took place (43.62%). Conversations lasted for 11-22 minutes. Mann-Whitney U test revealed association between duration of donor family communication and occurrence of refusal (P = .021). It was found that the relatives' education level, the number of staff, and the number of family members strongly influenced the occurrence of refusals. CONCLUSIONS: The careful preparation, organized direction, and support by intensive care unit staff can decrease the number of family refusals.

Role of early systemic inflammatory response in simultaneous pancreas-kidney transplantation.

Pancreas grafts are susceptible to surgical complications mostly related to exocrine secretions and the low microcirculatory blood flow through the gland. During simultaneous kidney-pancreas transplantation, the systemic response depends on reperfusion of two organs acute graft pancreatitis, immunotherapy, coagulopathy, bleeding, and other factors. We performed a retrospective review of 10 adult simultaneous pancreas-kidney transplant patients to evaluate progression of early postoperative inflammation in the absence of infection. All patients were treated with four-drug therapy. We performed analyses of procalcitonin (PCT), C-reactive protein, serum creatinine, amylase, and lipase levels over the first 5 postoperative days. Relatively high peak PCT levels (maximum 130 ng/mL) were reached within 24 to 48 hours postoperatively followed by a moderate decrease. Consistent with this observation, the serum creatinine, amylase, and lipase levels decreased continuously to normal concentrations within the first week. The increased PCT levels seemed depend upon the surgical procedure and intraoperative events. PCT was superior to C-reactive protein to discriminate infection from inflammation in this setting. The dynamics of PCT levels, rather than absolute values, seemed to be important. Lack of a decrease in PCT levels after the peak, suggested an infectious complication or the development of sepsis. Monitoring and assessment of PCT levels may help in early recognition of infection and institution of therapy.

Help, I need to develop communication skills on donation: the "VIDEO" model.

BACKGROUND: Information about brain stem death and donation can be influence the consent rate for donation and its psychosocial effects. The aim of this study was to create a "VIDEO" model that could be used to help physicians to develop communication skills. METHODS: A video recorded 32 simulations of family interviews: 16 under-age and 16 adult donors. They were analyzed during 8 courses conducted in 2008 and 2009. During the VIDEO process, the visual presentation was followed by participants (n=192) discussing interactively the donation situation. After the transcription of the video records, family interviews were explored retrospectively regarding informing relatives about brain stem death and donation, typical communication gaps and common questions from families. The data were examined qualitatively and semiquantitatively. We think that teaching can be optimized by our results. RESULTS: A comprehensible explanation about brain stem death was provided to relatives in 65.63% of cases. The consent of the family was more important for the physicians than the application of the law in 93.75%; 78.13% of physicians emphasized altruism to support donation. Remarkable mistakes of communication included using the teams coma and brain stem death interchangeably (9.38%); applying expressions connected with life in the present tense (21.88%) and mechanically kept alive (21.88%); organ-focused behavior such as "organs to be usable" (34.38%). The frequent questions and statements of "relatives" were "heart beats" (100%), "did he really die?" (65.63%), "fear of loss of integrity of the corpse" (59.38%), and "wake up from the coma" (46.88%). DISCUSSION: Interaction with the family requires great preparation. The communication skills of physicians can be developed through the VIDEO model. The results can be integrated into educational programs that consider the particular features of the given country.

Volumetric hemodynamic changes and postoperative complications in hypothermic liver transplanted patients.

INTRODUCTION: Hepatic diseases decrease the liver's involvement in thermoregulation. Removal of the liver during transplantation increases the incidence of hypothermia during the surgery. The aims of the present study were to analyze the hemodynamic changes among hypothermic liver transplantations and to determine its relationship to postoperative complications. METHODS: Conventional and volumetric hemodynamic monitoring and intramucosal pH measurements were performed during 54 liver transplantations. According to the core temperature until graft reperfusion, patients were classified into group A, hypothermic patients (temperature < 35 °C; n=25) versus group B, normothermic patients (temperature > 36 °C; n=29). We examined the relationships between central venous pressure (CVP), intrathoracic blood volume index, cardiac index (CI), and oxygen delivery index, oxygen consumption index, as well as the fluctuation of the mean arterial pressure (MAP) and gastric intramucosal pH and activated clotting time. We recorded prolonged ventilation time, vasopressor and hemodialysis requirements, occurrence of infections, and intensive care days. RESULTS: There were no significant differences in the MELD scores. More Child-Pugh class C patients (P<.01) showed significantly higher APACHE II scores (P<.02) among group A. During hepatectomy and at the same intrathoracic blood volumes, the hypothermic group showed significantly higher CVP levels (P<.02). During the anhepatic and postreperfusion phases, the decreased CI levels (P<.05) were associated with increased MAP values (P<.05). Without differences in oxygen delivery, the oxygen consumption was lower in group A (P<.05). The intramucosal pH levels were the same in the both groups during the whole examination period. More instances of infection, intensive care, and hemodialysis treatment days, were observed as well as significantly longer vasopressor requirements and coagulopathy among the hypothermic group (P<.007).

Epidural anesthesia? No of course.

Although the contraindications for thoracic epidural anesthesia (TEA) are well defined, the debate continues about whether TEA improves outcomes. Pro and con trials and a metaanalysis in the past have yielded equivocal results; they did not deal with new vascular intervention or drugs. The benefit of TEA in surgery is to provide analgesia. In subgroups, TEA can decrease the mortality and morbidity. In contrast, the cost can increase in the situation of a complication that is opposite to the side effects is rare, but the impairment caused by them is out of proportion to the benefits. Primary or secondary prophylaxis with antithrombotic drugs is increasing in developed countries because of the increasing cardiovascular interventions and aging of the population. The neuroaxial guidelines are useful, but the changing of the coagulation profile after hepatectomy is not included in them. The decision to use TEA in liver surgery must be individualized with steps planned from the beginning. TEA suitability is based on an evaluation of the contraindications, comorbidities, coagulation profiles, hepatic reserve, and balance of benefits and risks. The insertion or withdrawal of the epidural catheter should be made with care according to the neuroaxial guidelines and in the presence of a normal TEG. The decreasing level of prothrombin content and platelet counts after hepatectomy should be closely monitored every 2 to 5 days.