Intraoperative intracardiac thrombus in liver transplantation: A 9-year retrospective review focusing on treatment and outcomes.

This study characterizes incidence and outcomes surrounding intracardiac thrombosis (ICT) during liver transplantation over 9 years at a single center before and after the routine use of transesophageal echocardiography (TEE). Adult liver transplantation patients from 2011 to 2020 were divided into eras based on routine TEE use. ICTs were identified by querying anesthetic records for search terms. Descriptive statistics included counts and proportions for baseline recipient, donor, intraoperative, and postoperative characteristics. Outcome data were based on date of hospital discharge and date of death. The incidence of ICT increased in the TEE era (2016-2020) compared with the pre-TEE era (2011-2015; 3.7% [25/685] vs. 1.9% [9/491]; p < 0.001). Patients with ICT had significantly higher Model for End-Stage Liver Disease-sodium (MELD-Na) scores, pretransplant hospitalization, malignancy, drug-induced liver injury, hypertension, deep vein thrombosis, reperfusion syndrome, transfused platelets and cryoprecipitate, and use of hemostatic medications. A higher proportion of patients in the ICT group underwent simultaneous liver-kidney transplantation. The patients with ICT were similar, except patients in the pre-TEE era had higher MELD-Na scores and incidences of hepatitis C virus and lower incidences of encephalopathy. In the pre-TEE era, all ICTs presented as intraoperative cardiac arrest, and the 30-day mortality in the setting of ICT was 66.7% (6/9). During the TEE era, 80% of ICTs were diagnosed incidentally or attributed to hemodynamic instability (p = 0.002). The 30-day mortality rate was 36% (9/25) in the TEE era (p = 0.25). ICT incidence increased in the TEE era, yet the mortality rate was lower, suggesting that routine intraoperative TEE may lead to the early detection of ICT prior to hemodynamic collapse.

The Optimal Cell Salvage Settings to Maximize Hematocrit and Minimize Potassium Using the Cobe BRAT2 Autologous Blood Recovery Unit.

OBJECTIVE: The objective was to determine the optimal cell saver device settings (infusion rate and wash rate) at which hematocrit is preserved and potassium and lactate are removed from banked red blood cells (RBC). DESIGN: Red cells were washed using the Cobe BRAT 2 Autologous Blood Recovery Unit and sampled for electrolyte composition and hematocrit pre- and postwash. SETTING: This was a single-center study. INTERVENTIONS: Red cells were washed using six infusion rates (100-1,000 mL/min) and six wash rates (100-1,000 mL/min) for a total of 36 combinations. Hematocrit, potassium, glucose, and lactate were evaluated before and after washing. MEASUREMENTS AND MAIN RESULTS: At wash rates ≤400 mL/min, hematocrit increased independent of infusion rate. At wash rates ≥400 mL/min, slower infusion rates were associated with higher hematocrit compared to faster infusion rates (p < 0.0001 for a wash rate 400-800 mL/min, p < 0.0005 for a wash rate 1,000 mL/min). Maximal wash speeds were associated with decreasing hematocrit. Infusion and wash rate were both independent predictors of potassium change; slower rates were associated with a larger decrease in potassium. Glucose decreased proportionally as infusion and wash rate decreased. Lactate did not show an association with either infusion or wash rate. CONCLUSION: Red-cell washing produces higher hematocrit and lower potassium as infusion rate and wash rate decrease. A 340-mL unit of RBC can be processed in 4.26 minutes without loss of hematocrit or an increase in potassium when both infusion and wash rates are set to 400 mL/min.

Evaluation of the addition of bupivacaine to intrathecal morphine for intraoperative and postoperative pain management in open liver resections.

BACKGROUND: Intrathecal morphine is a popular and effective regional technique for pain control after open liver resection, but its delayed analgesic onset makes it less useful for the intraoperative period. The aim of this retrospective study was to compare the analgesic efficacy and other secondary benefits of the addition of hyperbaric bupivacaine to intrathecal morphine ± fentanyl. We hypothesized that bupivacaine could serve as an analgesic "bridge" prior to the onset of intrathecal morphine/fentanyl thereby lowering opioid consumption and enhancing recovery. METHODS: Cumulative intraoperative and postoperative opioid consumption as well as other intra- and postoperative variables were collected and compared between groups receiving intrathecal morphine alone or intrathecal morphine ± hyperbaric bupivacaine. RESULTS: Sixty-eight patients were selected for inclusion. Cumulative intraoperative morphine consumption was significantly reduced in the bupivacaine group while other intraoperative parameters such as intravenous fluids, blood loss, and vasopressors did not differ. There was a statistically significant improvement in time to first bowel movement in the experimental group. DISCUSSION: The intraoperative opioid sparing effects and improved time to bowel function with the addition of hyperbaric bupivacaine to intrathecal morphine may make this technique an easy and low risk method of enhancing recovery after open liver resection.

Orthotopic liver transplant in the pregnant recipient: A systematic review of preoperative management and maternal and fetal outcomes.

Severe liver dysfunction requiring transplantation is a major event at any stage of life, but for those requiring liver transplantation while pregnant, two lives hang in the balance. Available evidence on this relatively rare event consists solely of case reports and have yet to be reviewed or synthesized. We performed a systematic literature review and analyzed reports of 22 patients who underwent liver transplantation during pregnancy. This review describes the reported etiologies of hepatic failure in pregnant patients requiring transplantation, perioperative anesthetic management techniques, and the maternal and fetal clinical outcomes.

A Case Report of Venoarterial ECMO as Salvage Therapy for Prolonged Cardiac Arrest Following Post-Reperfusion Intracardiac Thrombosis During Orthotopic Liver Transplantation.

In this report we describe the use of intraoperative venoarterial ECMO as salvage therapy in a unique case of post-reperfusion intracardiac thrombosis during liver transplantation with prolonged ACLS and coagulopathy. The limited literature on intraoperative ECMO as salvage therapy in liver transplantation is reviewed.

Abdominal Organ Transplantation: Noteworthy Literature in 2019.

In the year 2019, we identified and screened over 400 peer-reviewed publications on pancreatic transplantation, over 200 on intestinal transplantation, and over 1900 on kidney transplantation. The liver transplantation section focuses on and features selected articles among 70 clinical trials published in 2019. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a broad range of topics, including risks for and prediction of perioperative complications, updated indications for transplantation, recommendations on perioperative management, including Enhanced Recovery After Surgery programs, and topics relevant to optimization of patient and graft outcomes and survival.

Retrospective Analysis of Obstetric Intensive Care Unit Admissions Reveals Differences in Etiology for Admission Based on Mode of Conception.

BACKGROUND: The use of in vitro fertilization is increasing. The incidence of adverse outcomes is greater for women who undergo in vitro fertilization, potentially leading to intensive care unit admission. This study aimed to assess the etiology and course of intensive care unit admission in women who underwent in vitro fertilization compared to those who did not, with specific focus on intensive care unit admission due to postpartum hemorrhage. METHODS: In this retrospective study, medical records of patients admitted to the intensive care unit during pregnancy or the peripartum period at 2 medical centers (2005-2016 at Mount Sinai Hospital, New York, NY, and 2005-2013 at Shaare Zedek Medical Center, Jerusalem, Israel) were analyzed. Demographic, past medical and obstetric history, and details regarding delivery and intensive care unit stay were collected, as was information regarding mode of conception (in vitro fertilization versus non-in vitro fertilization) for the current pregnancy. The primary outcome measure was difference in etiology of intensive care unit admission between in vitro fertilization and non-in vitro fertilization groups. Secondary outcome measures included differences in prepregnancy characteristics, incidence, severity, and management of postpartum hemorrhage, as well as incidence of other clinical major morbidity events and delivery-related complications. Multivariable logistic regression was performed to study the relationship between in vitro fertilization and the odds of having been admitted to the intensive care unit due to hemorrhage. RESULTS: During the study period, there were nearly 192,000 deliveries, with 428 pregnant and peripartum women admitted to the intensive care unit. Of the 409 cases analyzed, 60 had conceived following in vitro fertilization and 349 had conceived without in vitro fertilization. The non-in vitro fertilization group was more likely to have multiple medical comorbidities, and the in vitro fertilization group was more likely to have multiple gestations. The groups also differed in etiology of intensive care unit admission; more women in the in vitro fertilization group were admitted due to a pregnancy-related complication. Intensive care unit admission for postpartum hemorrhage was more frequent in the in vitro fertilization group (60.0% vs 43.1%, P = .014), with a 2-fold increase in the incidence of hemorrhagic shock. Logistic regression analysis revealed a 2-fold increase in the odds that intensive care unit admission was due to hemorrhage in women undergoing in vitro fertilization, a finding that was not statistically significant when multiple gestation was added to the model. CONCLUSIONS: Among patients admitted to the intensive care unit, patients with different modes of conception had dissimilar etiologies for intensive care unit admission with intensive care unit admission due to hemorrhage greater in those with in vitro fertilization. Higher rates of multiple gestation pregnancies may explain this difference. Differences in pregnancies conceived via in vitro fertilization versus without in vitro fertilization may affect the obstetric intensive care unit case mix.

Clinical impact of intraoperative hyperlactatemia during craniotomy.

OBJECT: Patients often develop markedly elevated serum lactate levels during craniotomy although the reason for this is not entirely understood. Elevated lactate levels have been associated with poor outcomes in critically ill septic shock patients, as well as patients undergoing abdominal and cardiac surgeries. We investigated whether elevated lactate in craniotomy patients is associated with neurologic complications (new neurological deficits) as well as systemic complications. METHODS: We performed a cohort study of elective craniotomy patients. Demographic and intraoperative data were collected, as well as three timed intraoperative arterial lactate values. Additional lactate, creatinine and troponin values were collected immediately postoperatively as well as 12 and 24 hours postoperatively. Assessment for neurologic deficit was performed at 6 hours and 2 weeks postoperatively. Hospital length-of-stay and 30-day mortality were collected. RESULTS: Interim analysis of 81 patients showed that no patient had postoperative myocardial infarction, renal failure, or mortality within 30 days of surgery. There was no difference in the incidence of new neurologic deficit in patients with or without elevated lactate (10/26, 38.5% vs. 15/55 27.3%, p = 0.31). Median length of stay was significantly longer in patients with elevated lactate (6.5 vs. 3 days, p = 0.003). Study enrollment was terminated early due to futility (futility index 0.16). CONCLUSION: Elevated intraoperative serum lactate was not associated with new postoperative neurologic deficits, other end organ events, or 30 day mortality. Serum lactate was related to longer hospital stay.

Iron absorption in raw and cooked bananas: a field study using stable isotopes in women.

BACKGROUND: Banana is a staple food in many regions with high iron deficiency and may be a potential vehicle for iron fortification. However, iron absorption from bananas is not known. OBJECTIVE: The objective of this study was to evaluate total iron absorption from raw and cooked bananas. DESIGN: Thirty women (34.9±6.6 years) from rural Mexico were randomly assigned to one of two groups each consuming: 1) 480 g/day of raw banana for 6 days, or 2) 500 g/day of cooked banana for 4 days. Iron absorption was measured after extrinsically labeling with 2 mg of (58)Fe and a reference dose of 6 mg (57)Fe; analysis was done using ICP-MS. RESULTS: Iron content in cooked bananas was significantly higher than raw bananas (0.53 mg/100 g bananas vs. 0.33 mg/100 mg bananas, respectively) (p<0.001). Percent iron absorption was significantly higher in raw bananas (49.3±21.3%) compared with cooked banana (33.9±16.2%) (p=0.035). Total amount of iron absorbed from raw and cooked bananas was similar (0.77±0.33 mg vs. 0.86±0.41 mg, respectively). CONCLUSION: Total amount of absorbed iron is similar between cooked and raw bananas. The banana matrix does not affect iron absorption and is therefore a potential effective target for genetic modification for iron biofortification.

Concentraciones sanguineas de ferritina, vitamina B12, folato y factores asociados con anemia en el embarazo / Associated factors with anemia in pregnancy

El requerimiento de micronutrientes es fundamental en el desarrollo biológico del individuo, especialmente en la mujer gestante. El objetivo del estudio fue evaluar el estado nutricional de una submuestra, de 100 mujeres dentro del primer trimestre de embarazo, escogida en forma aleatoria simple a partir de una muestra de 900 gestantes, del estudio Anemia y estado nutricional de la gestante y el recién nacido atendidos en los hospitales de 1-11 nivel de la Secretaría Distrital de Salud de Bogotá 1997-1999 realizado por la Subdirección de nutrición del Instituto Nacional de Salud. Se utilizaron como indicadores bioquímicos del estado nutricional de la población hemoglobina, ferritina, folato y vitamina B12. Se encontró anemia en un 30 por ciento de la población y el grupo más afectado fue el de 13-19 años con un 11 por ciento, debido al incremento en las necesidades de nutrientes en la gestación y adicionalmente los del crecimiento y desarrollo. La deficiencia de fenitina fue del 31.9 por ciento, con el mayor porcentaje en el grupo de 20 a 24 años (14 por ciento). La deficiencia de vitamina B12 se presentó en el 15.9 por ciento de las gestantes, con predominio entre 13-19 años (5 por ciento). no se encontró deficiencia de folato en las muestras analizadas. El riesgo relativo para la presentación de anemia en las gestantes con deficiencia severa de ferritina fue de 1.99, P<0.05 (Mantel-Haenszel) y de 1.44, P>0,05 para las personas con deficiencia de vitamina B12. El consumo diario de alimentos fuentes de vitamina B12, es un factor protector contra su deficiencia (RR=5.77, P<0.05)

Conocimientos, actitudes y practicas sobre lactancia materna de las mujeres en edad fértil y del personal de salud del municipio de Guateque

El propósito del estudio fue el de identificar los factores que influyen en la disminución de la práctica de la lactancia materna, observada en el municipio de Guateque. En la presente investigación se identificaron los conocimientos, actitudes y prácticas sobre lactancia materna de las mujeres en edad fértil asistentes a las consultas de control prenatal, crecimiento y desarrollo o nutrición y del personal de salud del Hospital Regional San Rafael de Guateque. El estudio de tipo descriptivo utilizó la técnica de la encuesta. Para la recolección de información se diseñó un cuestionario para cada uno de los grupos del estudio. Los resultados permitieron identificar tanto en las mujeres en edad fértil, como en el personal de salud algunos conocimientos, actitudes y prácticas inadecuadas sobre lactancia materna, que pueden ser modificadas a través de programas educativos. De acuerdo con los propósitos del estudio, se elaboraron los delineamientos de un programa educativo para el personal de salud del Hospital Regional San Rafael de Guateque, los cuales a su vez puedan ser utilizados por los grupos y comités de apoyo a la lactancia materna en el municipio de Guateque