Evaluation of Plasma Disappearance Rate Indocyanine Green Clearance as a Predictor of Liver Graft Rejection in Donor Brain Death.

INTRODUCTION: There currently exist no quantitative methods to assess graft viability before the donor procurement procedure. In Europe, around 20% of liver grafts evaluated "in situ" by an experienced surgeon are discarded. The aim of this study is to evaluate the use of the plasma disappearance rate indocyanine green (PDR-ICG) clearance in predicting liver graft rejection to avoid this 20% of futile surgeries. OBJECTIVES: To evaluate PDR-ICG as a predictor of liver graft rejection in death brain donors compared with the gold standard evaluation by an experienced surgeon. MATERIAL AND METHODS: Prospective observational single center study. From March 2017 to July 2019, 29 donors were included in the study, 17 were men and 12 women with a median age of 68 years ± 16.9 years. Donors had an intensive care unit stay of 2 days ± 4 days. PDR-ICG was measured with PICCO2 monitor. Indocyanine green clearance dose was 0.25 mg/kg injected intravenously in the operating room just before donor procurement procedure is initiated. The surgeon was unaware of the PDR-ICG measure until the decision of graft acceptance was taken. Data regarding the donors and biopsy results were included in a prospective database. RESULTS: PDR-ICG measure could be obtained in 10 minutes in all of the cases included. The median PDR-ICG obtained was 18%/min (range, 2.4-31%/min). Graft rejection took place in 15 out of the 29 donors. PDR-ICG value was less than 10%/min in 6 of these rejected grafts and less than 15%/min in 10 donors. All donor grafts with PDR-ICG <15% were discarded. The graft had been discarded in 5 donors with a PDR-ICG >15%. CONCLUSIONS: In our study a plasma disappearance rate <10 would have identified the grafts that would be rejected, thus avoiding the displacement work and expense of the surgical team. These results should be confirmed in a multicentric study.

Donor Risk Index Has an Impact in Intraoperative Measure of Hepatic Artery Flow and in Clearance of Indocyanine Green: An Observational Cohort Study.

BACKGROUND: The increase in indications for liver transplantation has led to acceptance of donors with expanded criteria. The donor risk index (DRI) was validated with the aim of being a predictive model of graft survival based on donor characteristics. Intraoperative arterial hepatic flow and indocyanine green clearance (plasma clearance rate of indocyanine green [ICG-PDR]) are easily measurable variables in the intraoperative period that may be influenced by graft quality. Our aim was to analyze the influence of DRI on intraoperative liver hemodynamic alterations and on intraoperative dynamic liver function testing (ICG-PDR). METHODS: This investigation was an observational study of a single-center cohort (n = 228) with prospective data collection and retrospective data analysis. Measurement of intraoperative flow was made with a VeriQ flowmeter based on measurement of transit time (MFTT). The ICG-PDR was obtained from all patients with a LiMON monitor (Pulsion Medical Systems AG, Munich, Germany). DRI was calculated using a previously validated formula. Normally distributed variables were compared using Student's t test. Otherwise, the Mann-Whitney U test or Kruskal-Wallis test was applied, depending on whether there were 2 or more comparable groups. The qualitative variables and risk measurements were analyzed using the chi-square test. P < .05 was considered statistically significant. RESULTS: DRI score (mean ± SD) was 1.58 ± 0.31. The group with DRI >1.7 (poor quality) had an intraoperative arterial flow of 234.2 ± 121.35 mL/min compared with the group having DRI < 1.7 (high quality), with an intraoperative arterial flow of 287.24 ± 156.84 mL/min (P = .02). The group with DRI >1.70 had an ICG-PDR of 14.75 ± 6.52%/min at 60 minutes after reperfusion compared to the group with DRI <1.70, with an ICG-PDR of 16.68 ± 6.47%/min at 60 minutes after reperfusion (P = .09). CONCLUSION: Poor quality grafts have greater susceptibility to ischemia-reperfusion damage. Decreased intraoperative hepatic arterial flow may represent an increase in intrahepatic resistance early in the intraoperative period.

Velocidad de incorporación de nuevos medicamentos en la práctica clínica / Time required to introduce new drugs into clinical practive

Objetivo: Analizar la velocidad de incorporación de nuevos medicamentos en la práctica clínica. Diseño: Estudio descriptivo retrospectivo. Unidad de estudio: Principios activos comercializados entre enero de 2003 y junio de 2004, excluidos los de uso estacional y los que no tienen establecida la dosis diaria definida (DDD). Emplazamiento: Primeros 2 años de comercialización de cada fármaco en atención primaria y atención especializada, en Aragón. Unidad de medida: Facultativos distintos que prescriben mensualmente cada fármaco y consumo mensual (DDD y gasto). Se utilizan las medias móviles de 3 meses. Se analizan también las categorías de aportación terapéutica. Resultados: En el cuarto mes se han incorporado el 33% de los facultativos que realizan alguna prescripción durante el primer año (35,6% intervalo de confianza (IC) del 95% 25,5-45,8), en el cuarto mes en atención primaria (31,5%, IC del 95% 21,4-41,5) y el primer mes en atención especializada (22,5%, IC del 95% 11,2-33,7). El 33% del consumo mensual máximo en DDD se alcanza en el cuarto mes durante el primer año (31,3% IC del 95% 22,2-40,5), en el quinto mes en atención primaria (25,4$%, IC del 95%: 10,7-40,2) y el primer mes en atención especializada (34,0%, IC del 95% 25,9-42,2). Los resultados en el segundo años son similares y el consumo máximo de DDD se produce un mes más tarde. No se aprecian diferencias según las categorías de aportación terapéutica. Conclusiones. La atención especializada se incorpora más rápidamente que la atención primaria. La velocidad de incorporación no parece relacionada con la aportación terapéutica. Para que los profesionales tengan la información sobre la utilización de nuevos medicamentos en un tiempo útil es necesario que dispongan de evaluaciones objetivas sobre su aportación terapéutica, como mínimo, antes del cuarto mes tras su comercialización (AU)

Objective: To analyze the time it takes for new medications to be introduced into clinical practice. Design: A retrospective, descriptive study focusing on the active ingredients commercialized between January 2003 and June 2004, with the exception of those of seasonal use and those for which the defined daily dose (DDD) had not yet been established. Study period and site: the first two years of commercialization of each drug employed in Primary Care and Specialized Care in Aragon, a region in northeastern Spain. Unit of measurement: The different physicians who prescribed each drug on a monthly basis and the monthly use (DDD and cost9. Moving averages of here months were utilized. Categories of therapeutic contribution were also analyzed. Results. By the fourth month, 33% of the physicians who made any prescriptions during the first year had become incorporated (35,6%, 95% CI:25,5%-45,8%) (4º month in Primary Care (31,5%, 95% CI; 21,4%-41,5%) and 1st month in Specialized Care (22,5%, 95% CI: 11.2%-33.7%). Thirty-three percent of the maximum monthly consumption in DDD was reached by the fourth month during the first year (31.3%, 95% CI: 22.2%-40,5%) (5th month in Primary Car (25,4%, 95% CI: 10,7%-40,2%) and 1st month in Specialized Care (34,0%, 95% CI: 25,9%-42,2%)). The results in the second year were similar, with the maximum consumption in terms of DDD occurring one month later. No differences were observed according to the category mary Care. The time required for incorporation does not appear to be related to the therapeutic contribution. In order for health care professionals to receive information on the utilization of new medications within a useful time frame, the must be provided with objective evaluations of the therapeutic contribution of these drugs within no more than four months of their commercialization (AU)