Role of Transesophageal Echocardiography in the Diagnosis of Multi-chamber Intracardiac Thrombosis During Liver Transplantation: A Case Series.

Intra-cardiac thrombosis is one of the most devastating complications during liver transplantation. In the majority of cases, ICT, followed by massive pulmonary embolism, is commonly occurring shortly after liver graft reperfusion, but it has been reported to occur at any stage of the surgery. We present a series of 3 cases of intra-cardiac thrombosis during orthotopic liver transplantation surgery, including a case of four-chamber intra-cardiac clot formation during the pre-anhepatic stage. This article represents a single-centre 14 year-long experience. Intra-operative TEE is the gold standard to diagnose intra-cardiac thrombosis, monitoring its size, location and dynamics, as well as myocardial performance and the effects of resuscitation efforts.

Massive Pulmonary Artery Thromboembolism in a Liver Transplant Recipient: Case Study and Literature Review.

The hypercoagulable state in liver transplant recipients that may manifest as abnormal thrombus formation in large vessel structures, such as cardiac chambers and the pulmonary arteries, poses a substantial threat for the patient and graft survival. Massive pulmonary embolism is a rare, albeit potentially lethal, complication that may occur at any stage of liver transplant surgery. In this study, we present the case of a major perioperative thromboembolic event in a liver transplant recipient that had taken place in the early post-transplant period during the second-look surgery that was then successfully treated by catheter-directed clot removal. We will attempt to identify potential factors that may have been associated with abnormal thrombus formation.

Precision Medicine and its Role in the Treatment of Sepsis: A Personalised View.

In recent years, a new form of medicine has become increasingly significant, namely, personalised medicine (PM). PM is a form of care in which treatment is tailored for an individual patient. PM is about using multiple data sets to create a digital human mapping. A person's biological traits are determined by the interactions of hundreds of genes and gene networks, as well as external factors such as diet and exercise. Combining and then investigating these multiple databases with powerful statistical tools, allows a new understanding of how genetic intricacy drives health and disease and so leads to a closer personalised medical approach that targets each individual's unique genetic make-up. Sepsis is a systemic inflammatory response to infection, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiple organ dysfunction syndromes (MODS). Sepsis is the most common cause of death in intensive care patients. Treatments in an ICU may need to be adapted to the continuous and rapid changes of the disease, making it challenging to identify a single target. PM is thus seen as the future of sepsis treatment in the ICU. The fact that individual patients respond differently to treatment should be regarded as a starting point in the approach to providing treatment. The disease itself comes secondary to this concept.

Perioperative Stress-Induced (Takotsubo) Cardiomyopathy in Liver Transplant Recipients.

A comprehensive analysis of published cases of Takotsubo cardiomyopathy, occurred in liver transplant recipients in the perioperative period, has been attempted in this review. Predisposing factors, precipitating events, potential physiological mechanisms, acute and post-event management have been discussed.

Effects of Fibrinogen Levels and Platelet Counts on Viscoelastic Testing in Cirrhotic Patients.

INTRODUCTION: Cirrhotic patients have been considered for decades to have a pro-haemorrhagic pattern and were treated as such based on the results from standard coagulation tests. The aim of our study was to determine the effects of platelet count and fibrinogen levels on rotational thromboelastometry (ROTEM) parameters. METHODS: We prospectively included 176 patients with End-Stage Liver Disease (ESLD) admitted to our Intensive Care Unit prior to liver transplantation. Collected data consisted of severity scores, liver, renal and standard coagulation tests, fibrinogen levels, platelet counts and ROTEM parameters. Four ROTEM assays were performed (ExTEM, InTEM, ApTEM and FibTEM) and the following parameters included: CT - clotting time, CFT - clot formation time, MCF - maximum clot firmness, ML - maximum lysis, alpha angle, TPI - thrombin potential index, MaxV - maximum velocity of clot formation (MaxV), MaxVt - time to MaxV, MCE - maximum clot elasticity and AUC - area under the curve. RESULTS: Statistical analysis demonstrated a linear correlation between platelet counts and ExTEM TPI (R2 linear =0.494), ExTEM MaxV (R2 linear =0.253), ExTEM MCE (R2 linear = 0.351) and ExTEM MCF (R2 cubic = 0.498). Fibrinogen levels correlated linearly with ExTEM MCF (R2 linear = 0.426), ExTEM TPI (R2 linear = 0.544), ExTEM MaxV (R2 linear = 0.332), ExTEM MCE (R2 linear = 0.395) and non-linearly with ExTEM CFT (R2 cubic = 0.475). CONCLUSION: Fibrinogen levels and platelet counts had an important effect on both standard and derived ROTEM parameters. Further analysis is required in order to determine clinically oriented cut-off values below which severe coagulopathy would develop.

Severe Austrian Syndrome in an Immunocompromised Adult Patient - A Case Report.

BACKGROUND: Known also as Osler's triad, Austrian syndrome is a complex pathology which consists of pneumonia, meningitis and endocarditis, all caused by the haematogenous dissemination of Streptococcus pneumoniae. The multivalvular lesions are responsible for a severe and potential lethal outcome. CASE REPORT: The case of a 51-year-old female patient, with a past medical history of splenectomy, is presented. She developed bronchopneumonia, acute meningitis and infective endocarditis as a result of Streptococcus pneumoniae infection and subsequently developed multiple organ dysfunction syndromes which led to a fatal outcome. Bacteriological tests did not reveal the etiological agent. The histopathological examination showed a severe multivalvular endocarditis, while a PCR based molecular analysis from formalin fixed valvular tissue identified Streptococcus pneumoniae as the etiologic agent. CONCLUSIONS: The presented case shows a rare syndrome with a high risk of morbidity and mortality. Following the broad-spectrum treatment and intensive therapeutic support, the patient made unfavourable progress which raised differential diagnosis problems. In this case, the post-mortem diagnosis demonstrated multiple valvular lesions occurred as a result of endocarditis.

The Relevance of Coding Gene Polymorphysms of Cytokines and Cellular Receptors in Sepsis.

Sepsis is an injurious systemic host response to infection, which can often lead to septic shock and death. Recently, the immune-pathogenesis and genomics of sepsis have become a research topic focusing on the establishment of diagnostic and prognostic biomarkers. As yet, none have been identified as having the necessary specificity to be used independently of other factors in this respect. However the accumulation of current evidence regarding genetic variations, especially the single nucleotide polymorphisms (SNPs) of cytokines and other innate immunity determinants, partially explains the susceptibility and individual differences of patients with regard to the evolution of sepsis. This article outlines the role of genetic variation of some serum proteins which have the potential to be used as biomarker values in evaluating sepsis susceptibility and the progression of the condition.

Perioperative Management of Lactic Acidosis in End-Stage Liver Disease Patient.

Lactic acidosis (LA) in end-stage liver disease (ESLD) patients has been recognized as one of the most complicated clinical problems and is associated with increased morbidity and mortality. Multiple-organ failure, associated with advanced stages of cirrhosis, exacerbates dysfunction of numerous parts of lactate metabolism cycle, which manifests as increased lactate production and impaired clearance, leading to severe LA-induced acidemia. These problems become especially prominent in ESLD patients, that undergo partial hepatectomy and, particularly, liver transplantation. Perioperative management of LA and associated severe acidemia is an inseparable part of anesthesia, post-operative and critical care for this category of patients, presenting a wide variety of challenges. In this review, lactic acidosis applied pathophysiology, clinical implications for ESLD patients, diagnosis, role of intraoperative factors, such as anesthesia and surgery-related, vasoactive agents impact, and also current treatment options and modalities have been discussed.

Serum acidosis prior to reperfusion facilitates hemodynamic recovery following liver transplantation.

INTRODUCTION: Reperfusion is the most critical event during liver transplantation, and sustained leakage of acidic preservation solution from the liver graft contributes to marked hemodynamic instability. Recent laboratory studies with hepatocyte cultures have revealed that low pH may protect hepatocyte mitochondria against ischemia-reperfusion injury by inhibiting the mitochondrial permeability transition (MPT), the so-called "pH paradox." However, the clinical significance of this pH paradox theory remains largely unknown. In this study, we sought to determine whether there is an association between serum pH immediately prior to reperfusion and hemodynamic recovery after reperfusion and graft survival. METHODS: We analyzed retrospective data from 527 patients who underwent Orthotopic liver transplantation between 2003 and 2008. All patients were allocated to one of two groups: pH ≤ 7.32 or pH > 7.32, as measured 5 min before reperfusion. Case-control matching was performed using the propensity score to adjust for background differences between the two groups. Data were analyzed using Student's t-test and the χ (2) test. RESULTS: There were 85 patients in the pH ≤ 7.32 group and 385 patients in the pH > 7.32 group. The recovery of mean arterial pressure after hepatic artery reperfusion was significantly faster in the pH ≤ 7.32 group (slope of recovery: 0.0004 % vs. 0.0002 %/min, p = 0.041). Other parameters studied, including vasopressor dosage after reperfusion, did not show any statistically significant difference between groups. CONCLUSIONS: Our findings suggest that less aggressive treatment of acidosis with a slower rate of normalization of serum pH (from low to normal) after reperfusion promotes faster hemodynamic stabilization. These findings provide evidence to support the concept of the pH paradox, and may also substantiate the argument against the usage of alkalizing agents before reperfusion unless acidosis becomes clinically significant.

A randomized clinical trial testing the anti-inflammatory effects of preemptive inhaled nitric oxide in human liver transplantation.

Decreases in endothelial nitric oxide synthase derived nitric oxide (NO) production during liver transplantation promotes injury. We hypothesized that preemptive inhaled NO (iNO) would improve allograft function (primary) and reduce complications post-transplantation (secondary). Patients at two university centers (Center A and B) were randomized to receive placebo (n = 20/center) or iNO (80 ppm, n = 20/center) during the operative phase of liver transplantation. Data were analyzed at set intervals for up to 9-months post-transplantation and compared between groups. Patient characteristics and outcomes were examined with the Mann-Whitney U test, Student t-test, logistic regression, repeated measures ANOVA, and Cox proportional hazards models. Combined and site stratified analyses were performed. MELD scores were significantly higher at Center B (22.5 vs. 19.5, p<0.0001), surgical times were greater at Center B (7.7 vs. 4.5 hrs, p<0.001) and warm ischemia times were greater at Center B (95.4 vs. 69.7 min, p<0.0001). No adverse metabolic or hematologic effects from iNO occurred. iNO enhanced allograft function indexed by liver function tests (Center B, p<0.05; and p<0.03 for ALT with center data combined) and reduced complications at 9-months (Center A and B, p = 0.0062, OR = 0.15, 95% CI (0.04, 0.59)). ICU (p = 0.47) and hospital length of stay (p = 0.49) were not decreased. iNO increased concentrations of nitrate (p<0.001), nitrite (p<0.001) and nitrosylhemoglobin (p<0.001), with nitrite being postulated as a protective mechanism. Mean costs of iNO were $1,020 per transplant. iNO was safe and improved allograft function at one center and trended toward improving allograft function at the other. ClinicalTrials.gov with registry number 00582010 and the following URL:http://clinicaltrials.gov/show/NCT00582010.

Treatment of severe lactic acidosis during the pre-anhepatic stage of liver transplant surgery with intraoperative hemodialysis.

Severe uncompensated lactic acidosis manifesting during the pre-anhepatic stage of orthotopic liver transplant surgery is an uncommon event, but it poses serious concern because of the additional lactate production and impaired elimination by the liver that develops during the anhepatic and allograft reperfusion stages of the procedure. A man with end-stage liver disease secondary to hepatitis C and hemochromatosis and normal renal function, who developed severe lactic acidosis in the pre-anhepatic stage of liver transplantation, was treated successfully with intraoperative, continuous venovenous hemodialysis. Hemodialysis effectively corrected the patient's lactic acidosis and removed lactate, which contributed to hemodynamic stability during the anhepatic and graft reperfusion stages of his liver transplant surgery.

Anesthetic management of acute mesenteric ischemia in elderly patients.

Ischemic insult to the splanchnic vasculature can jeopardize bowel viability and lead to devastating consequences, including bowel necrosis and gangrene. Although acute mesenteric ischemia (AMI) may occur at any age, the elderly are most commonly affected due to their higher incidence of underlying systemic pathology, most notably atherosclerotic cardiovascular disease. Treatment options include pharmacology-based actions, endovascular, and surgical interventions. AMI remains a life-threatening condition with a mortality rate of 60% to 80%, especially if intestinal infarction has occurred and surgical intervention becomes emergent. Early recognition and an aggressive therapeutic approach are essential if the usually poor outcome is to be improved. Anesthetic management is complex and must account for comorbid disease as well as the patient's presumptive acute deterioration. Blood pressure support typically involves careful, but often massive, fluid resuscitation and may also additionally require pharmacologic support.

Anesthetic implications of the new anticoagulant and antiplatelet drugs.

In this review, we discuss the anesthetic implications of the new anticoagulant and antiplatelet drugs, focusing our discussion mainly on neuroaxial/regional anesthesia and central catheter placement issues. We offer practical recommendations for their use.

Total cell associated electrolyte homeostasis in rat spinal cord cells following apparently irreversible injury.

BACKGROUND: We investigated total electrolyte homeostasis in spinal cord cells of rats subjected to irreversible spinal cord trauma. MATERIAL/METHODS: Forty-two rats underwent total transection of spinal cord (Group 1); chemical neurolysis by 10% lidocaine overdose (Group 2); sham "injury" (Group 3). Spinal cords were isolated 24 h, 72 h or 7 days following injury. Total cellular Ca, Mg, Na and K were measured in the spinal cord thoracic or lumbar parts using an atomic absorption spectrometer. RESULTS: Group 1: A significant Ca, Mg, Na, and K efflux was observed in thoracic and lumbar parts 24 h following transection. By 72 h, a significant re-entrance of Ca was evident. By 168 h, an influx of all electrolytes was demonstrable, sometimes reaching concentrations above the pre-trauma levels. Group 2: Following 24 h, Na, K, Ca, and Mg concentrations dropped significantly both in thoracic and lumbar parts. By 72 h, the electrolyte re-entrance was evident in the thoracic, but not the lumbar part. By 168 h, Na, K, Ca, and Mg influx was observed both in thoracic and lumbar parts, the concentration approaching pre-trauma levels. Group 3: No changes in electrolyte content were observed in spinal cords of sham-operated animals. CONCLUSIONS: Following massive, apparently irreversible injury of the spinal cord, some restorative processes do take place at the cellular level. Subsequent supernormal accumulation of intracellular electrolytes, especially Ca, might eventually contribute to a secondary injury. Should this be the case, pharmacotherapeutic intervention might prove beneficial.