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4.
Transpl Int ; 2018 Oct 23.
Artigo em Inglês | MEDLINE | ID: mdl-30350894

RESUMO

Lung transplantation is a life-saving procedure limited by donor's availability. Lung reconditioning by ex vivo lung perfusion represents a tool to expand the donor pool. In this study, we describe our experience with the OCS™ Lung to assess and recondition extended criteria lungs. From January 2014 to October 2016, of 86 on-site donors evaluated, eight lungs have been identified as potentially treatable with OCS™ Lung. We analyzed data from these donors and the recipient outcomes after transplantation. All donor lungs improved during OCS perfusion in particular regarding the PaO2 /FiO2 ratio (from 340 mmHg in donor to 537 mmHg in OCS) leading to lung transplantation in all cases. Concerning postoperative results, primary graft dysfunction score 3 at 72 h was observed in one patient, while median mechanical ventilation time, ICU, and hospital stay were 60 h, 14 and 36 days respectively. One in-hospital death was recorded (12.5%), while other two patients died during follow-up leading to 1-year survival of 62.5%. The remaining five patients are alive and in good conditions. This case series demonstrates the feasibility and value of lung reconditioning with the OCS™ Lung; a prospective trial is underway to validate its role to safely increase the number of donor lungs.

5.
Turk J Anaesthesiol Reanim ; 46(3): 176-183, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30140512

RESUMO

Objective: Management of pain, agitation and delirium (PAD) remains to be a true challenge in critically ill patients. The pharmacological proprieties of dexmedetomidine (DEX) make it an ideal candidate drug for light and cooperative sedation, but many practical questions remain unanswered. This structured consensus from 17 intensivists well experienced on PAD management and DEX use provides indications for the appropriate use of DEX in clinical practice. Methods: A modified RAND/UCLA appropriateness method was used. In four predefined patient populations, the clinical scenarios do not properly cope by the current recommended pharmacological strategies (except DEX), and the possible advantages of DEX use were identified and voted for agreement, after reviewing literature data. Results: Three scenarios in medical patients, five scenarios in patients with acute respiratory failure undergoing non-invasive ventilation, three scenarios in patients with cardiac surgery in the early postoperative period and three scenarios in patients with overt delirium were identified as challenging with the current PAD strategies. In these scenarios, the use of DEX was voted as potentially useful by most of the panellists owing to its specific pharmacological characteristics, such as conservation of cognitive function, lack of effects on the respiratory drive, low induction of delirium and analgesia effects. Conclusion: DEX might be considered as a first-line sedative in different scenarios even though conclusive data on its benefits are still lacking.

6.
Prog Transplant ; 28(4): 314-321, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29879861

RESUMO

INTRODUCTION:: Extracorporeal membrane oxygenation (ECMO) is considered a reliable technique in lung transplantation requiring cardiorespiratory support. However, the impact of this technology on blood product transfusion rate and outcomes compared to off-pump lung transplantation has been rarely investigated. METHODS:: Between January 2012 and June 2015, 52 elective adult lung transplants were performed at our institution. Of these, 15 recipients required intraoperative venoarterial extracorporeal support and 37 did not. We compared blood product consumption and other outcome variables between the 2 groups. RESULTS:: We found comparable in-hospital (86.7% vs 97.3%, P = .14) and 6-month (86.7% vs 91.9%, P = .56) survival between patients with and without extracorporeal support, respectively. Survival at 30 days was lower in the ECMO group (86.7% vs 100%, P = .02). Although patients who underwent ECMO received more intraoperative transfusions, postoperative transfusion rate was similar between the 2 groups. The ECMO group experienced longer mechanical ventilation (median 3 vs 2 days, P = .02) and intensive care unit stay (median 7 vs 5 days, P = .02), besides more cardiogenic shock and deep vein thrombosis. However, we observed no difference in other major and minor in-hospital complications and 6-month complications. CONCLUSIONS:: In our experience, despite the higher need for intraoperative transfusions, lung transplantation performed with ECMO support is comparable to the off-pump procedure as to short-term survival and outcomes.

7.
Interact J Med Res ; 7(1): e2, 2018 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-29386170

RESUMO

BACKGROUND: NekNomination, also known as NekNominate, Neck and Nominate, or Neck Nomination, is a social network-based drinking game which is thought to have originated in Australia and spread all over the world between 2013 and 2014. Individuals record videos of themselves while rapidly drinking excessive quantities of alcoholic drinks (necking) and then nominate friends to outdo them within 24 hours; the videos are then posted on social media such as Facebook or YouTube. The consequences of this drinking game have been very dangerous; at least 5 people under age 30 years have died after drinking deadly cocktails, and many others have suffered from alcohol intoxication. OBJECTIVE: The goal of the research is to evaluate data about clinically important acute alcohol intoxication among teenagers and young adults and inform and educate the general public, especially parents, teachers, and health workers, about the spreading craze of dangerous Internet-related behavior among today's teenagers and young people up to the age of 23 years. METHODS: Patients aged 15 to 23 years with acute alcohol intoxication who came to the emergency department (ED) of 2 major hospitals in Italy from January 1, 2011, to June 30, 2014, were included in this study. Data were retrieved from prehospital and intrahospital medical records and included personal information, methods of intoxication, triage color code, date and time of access to the ED, any relevant signs and symptoms, blood alcohol concentration, and diagnosis at discharge. RESULTS: A total of 450 young patients (male 277/450, 61.5%, female 173/450, 38.5%; age 15 to 16 years 15/450, 3.3%, age 17 to 18 years 184/450, 40.9%, age 19 to 23 years 251/450, 55.8%) were recruited. The causes of intoxication were happy hour, binge drinking, NekNominate, eyeballing, other alcoholic games, or a mix of them. Happy hour was found to be more common among the older patients, whereas NekNominate accounted for almost half of the youngest group of hospitalizations. Eyeballing occurred in 1.6% (7/450) of cases; binge drinking and other alcoholic games caused 23.3% (105/450) and 23.8% (107/450) of hospitalizations, respectively. On admission, 44.2% (199/450) of patients were assigned a red or yellow color code requiring immediate medical attention; about 14% of them required additional medical assistance (after being in the ED) or hospitalization, some in semi-intensive care units. CONCLUSIONS: Our study shows that the increased numbers of hospitalizations due to alcohol intoxication in the adolescent age group, as a consequence of NekNominate or other drinking games, is alarming and represents a serious public health issue. The potential markers of improper use of social networks must be clearly identified, including categories at risk of alcohol abuse, in order to develop intervention and prevention strategies in terms of education and awareness, which may help in averting potentially fatal episodes.

8.
Clin Transplant ; 31(12)2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28972662

RESUMO

In rapidly deteriorating patients awaiting lung transplantation (LT), supportive strategies are only temporary and urgent lung transplant (ULT) remains the last option. The few publications on this topic report conflicting results. According to the Italian national program, patients on mechanical ventilation and/or extracorporeal membrane oxygenation (ECMO) may be included in urgent list. We reviewed our experience from January 2012 to December 2014 with ULT and elective lung transplantation (ELT), focusing on outcomes. In the study period, 16 patients received ULT, while 51 received ELT. Among ULT, 1 patient (5.8%) died in waiting list (WL) while 16 patients underwent LT with a median WL time of 6 days. ELT WL mortality was 13.5%, and median WL time 368 days. In-hospital mortality was lower in ELT group (5.8% vs 37.5%, P < .01), while the other postoperative outcomes were not significantly different. For ULT patients, the highest impact risk factors for in-hospital mortality were pretransplant plasma transfusion, recipient Pseudomonas aeruginosa colonization, and high level of reactive C-protein and lactic acid. A ULT program with an accurate recipient selection allows earlier transplantation, reducing WL mortality, with acceptable outcomes, although with a higher in-hospital mortality. Larger studies are needed to validate our results.


Assuntos
Emergências , Transplante de Pulmão , Complicações Pós-Operatórias , Doadores de Tecidos/provisão & distribução , Listas de Espera/mortalidade , Adulto , Oxigenação por Membrana Extracorpórea , Feminino , Seguimentos , Sobrevivência de Enxerto , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Adulto Jovem
9.
J Med Internet Res ; 19(4): e86, 2017 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-28365563

RESUMO

BACKGROUND: Cases of trauma resulting from the use of mobile phones while driving motor vehicles have become quite common in recent years. Road injuries incurred by people playing video games on mobile phones (or other media devices) while walking have also become a cause for concern. Pokémon Go has been the world's most popular game since it was launched in July 2016, with more than 15 million players trying to catch all Pokémon available in the game; however, the case detailed here is the first reported accident in the medical literature caused by a pedestrian distracted by the game while crossing a street. OBJECTIVE: We aim to provide additional information on the innovative nature of distractions that generate risks in road-users, and to explore the underreporting of pedestrian-motor vehicle collisions due to mobile device usage. METHODS: We included in this case report a 25-year-old male who suddenly crossed a road while playing Pokémon Go and was hit by a van, reporting several injuries and being assisted by the Emergency Medical Service of our hospital (Padova, Italy). The patient's history, the circumstances in which the collision happened, imaging data, and clinical course information were recorded per our hospital's privacy policy. RESULTS: The patient hit by the van was playing Pokémon Go on his mobile phone while crossing a street, despite red traffic lights, which he did not notice due to of the distraction induced by the game. CONCLUSIONS: Mobile videogames that imply movement (ie, walking, running, cycling) to play are an effective way to improve physical activity practice, especially in adolescents and young adults. Nevertheless, cases like the one presented here point out that these games could pose a significant risk to users who play while walking, cycling, or driving in unsafe areas such as city streets, because players become distracted and may ignore surrounding hazards. Comprehensive, multilevel interventions are needed to reduce accidents caused by distraction, and to stress findings on the positive and negative effects of video games, which are becoming a source of public health concern. Health care providers should be aware of their chief role in these possible prevention strategies, based on their direct interactions with road incident victims.


Assuntos
Acidentes de Trânsito , Direção Distraída , Pedestres/psicologia , Jogos de Vídeo/efeitos adversos , Adulto , Exercício , Humanos , Masculino , Assunção de Riscos
10.
Transplant Rev (Orlando) ; 31(3): 193-206, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28284465

RESUMO

Compromised liver function, as a consequence of acute liver insufficiency or severe chronic liver disease may be associated with various neurological syndromes, which involve both central and peripheral nervous system. Acute and severe hyperammoniemia inducing cellular metabolic alterations, prolonged state of "neuroinflammation", activation of brain microglia, accumulation of manganese and ammonia, and systemic inflammation are the main causative factors of brain damage in liver failure. The most widely recognized neurological complications of serious hepatocellular failure include hepatic encephalopathy, diffuse cerebral edema, Wilson disease, hepatic myelopathy, acquired hepatocerebral degeneration, cirrhosis-related Parkinsonism and osmotic demyelination syndrome. Neurological disorders affecting liver transplant candidates while in the waiting list may not only significantly influence preoperative morbidity and even mortality, but also represent important predictive factors for post-transplant neurological manifestations. Careful pre-transplant neurological evaluation is essential to define severity and distribution of the neurological impairment, to identify the abnormalities still responsive to current treatment, and to potentially predict the inherent post-operative prognosis. The preferred specific indices of neurological pre-transplant assessment may vary among centers, however, even with the aid of the current biochemical, neurophysiological, neuropsychological and neuroimaging diagnostic tools, the correct diagnosis and differential diagnosis of various syndromes may be difficult. In this article the relevant pathophysiological and clinical aspects of the most frequent brain and peripheral nervous system diseases affecting liver transplant candidates with acute or advanced chronic liver failure are briefly reported. The practical diagnostic findings useful for the preoperative assessment and treatment, as well as the expected neurological evolution after liver transplantation are also evaluated.


Assuntos
Falência Hepática/complicações , Transplante de Fígado , Doenças do Sistema Nervoso/complicações , Humanos , Falência Hepática/fisiopatologia , Falência Hepática/cirurgia , Doenças do Sistema Nervoso/fisiopatologia , Seleção de Pacientes
11.
Interact J Med Res ; 6(1): e4, 2017 Mar 23.
Artigo em Inglês | MEDLINE | ID: mdl-28336507

RESUMO

BACKGROUND: The monitoring and management of risks regarding children and young people admitted to the emergency department as a result of dangerous behaviors distributed via the Internet should be based on clinical reasoning and knowledge about these social media-related phenomena. Here we examine 2 cases of teenagers who reported severe injuries while performing the "planking" craze, a challenge that consists in lying face-down stiffly like a board on any kind of surface. OBJECTIVE: Our objective is to examine and describe the Internet craze called planking, also known as the "lying-down game," through 2 case reports from our experience, enriching this study with information gained through discussions with secondary school teenagers. METHODS: Details of the 2 case reports were taken from electronic medical records giving information on care support processes, care management, and the costs of traumatic episodes. Demographic data, hemoglobin and serum lactate values, and Injury Severity Scores were evaluated. The study took place in secondary schools of our city from 2013 to 2014 during medical education courses, with the aim of analyzing the influence of social media on teenagers' activities and behaviors. RESULTS: Both patients suffered multiple trauma injuries and needed high-level health assistance. The first patient underwent a splenectomy and the second one a nephrectomy; both of them required a long hospital stay (14 and 20 days, respectively), and the costs for their management have been estimated at US $27,000 and US $37,000, respectively. Their decision to perform the planking in dangerous locations was due to their ambition to gain peers' acclaim through shared videos and pictures. CONCLUSIONS: Reporting and understanding these cases may potentially help prevent future events occurring in similar circumstances: the scientific community cannot leave this problem unaddressed. There is also a role of education resources for health care professionals; for this, we must identify and follow up strange or misleading information found on websites. A key element of this research study was to report physicians' misperceptions concerning planking and, with these cases used for teaching purposes, improve knowledge of the clinical and forensic aspects of this emerging problem.

12.
J Clin Anesth ; 35: 198-204, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27871520

RESUMO

BACKGROUND: Postoperative residual neuromuscular blockade (RNMB) is a common complication in the postanesthesia care unit (PACU), but also one of the most controversial issues. Many studies and trials demonstrated that some methods and techniques can reduce the incidence and the extent of the phenomenon. STUDY OBJECTIVE: To determine the incidence of RNMB in the PACU at standardized times after extubation with the implementation of a protocol of careful neuromuscular blockade management. DESIGN: Randomized, single-blinded controlled clinical trial. SETTING: Operating room and PACU. PATIENTS: A total of 120 patients of either sex with American Society of Anesthesiologists grades 1, 2, and 3, aged 18 to 80 years were scheduled to undergo elective abdominal surgical procedures lasting for at least 60 minutes. INTERVENTIONS: Patients were randomized to receive either cisatracurium (n=60) or rocuronium (n=60) at the time of intubation and during surgery. Every patient received quantitative neuromuscular monitoring during general anesthesia. On completion of surgery, patients were given neostigmine 0.05 mg kg-1. Patients were extubated at a train-of-four (TOF) ratio≥0.9. MEASUREMENTS: TOF measurements were performed 15, 30, and 60 minutes after extubation. Tolerability of neuromuscular monitoring was evaluated with a scale from 1 to 10 (with 1 meaning no discomfort at all and 10 meaning maximal discomfort or pain). RESULTS: Six, 11, and 14 patients (5.0%, 9.2%, and 11.7%) exhibited a TOF ratio <0.9 at 15, 30, and 60 minutes after extubation, respectively. No statistically significant difference in the postoperative RNMB between cisatracurium and rocuronium was found. The median tolerability score for neuromuscular monitoring was 3. CONCLUSION: Careful conduction, monitoring, and subsequent reversal of neuromuscular block may allow for obtaining considerably low incidence of residual neuromuscular block. However, our trial shows that some mid- and long-term cases of TOF ratios <0.9 can still occur, possibly jeopardizing the patients' postoperative recovery.


Assuntos
Androstanóis/efeitos adversos , Atracúrio/análogos & derivados , Inibidores da Colinesterase/administração & dosagem , Recuperação Demorada da Anestesia/epidemiologia , Neostigmina/administração & dosagem , Bloqueio Neuromuscular/efeitos adversos , Fármacos Neuromusculares não Despolarizantes/efeitos adversos , Adulto , Idoso , Extubação , Androstanóis/administração & dosagem , Período de Recuperação da Anestesia , Atracúrio/administração & dosagem , Atracúrio/efeitos adversos , Recuperação Demorada da Anestesia/induzido quimicamente , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/efeitos adversos , Monitoração Neuromuscular/efeitos adversos , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Rocurônio , Método Simples-Cego , Adulto Jovem
13.
Crit Care Med ; 44(7): e589-90, 2016 07.
Artigo em Inglês | MEDLINE | ID: mdl-27309181
14.
Pain Physician ; 18(4): 343-8, 2015 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26218937

RESUMO

BACKGROUND: Spontaneous intracranial hypotension (SIH) results from leaks developing in the dura mater. The major symptom is orthostatic headache which gradually disappears after lying down. Lumbar epidural blood patches (EBPs) can be effective in relieving headaches, however, thoracic and cervical EBPs have also been applied to alleviate the symptoms. OBJECTIVE AND METHODS: Retrospective collection of the main characteristics of SIH, site and amount of blood injection, and clinical outcomes of 18 patients who underwent thoracic EBPs for intractable SIH. STUDY DESIGN: Retrospective case series RESULTS: All thoracic autologous EBPs except 3 were performed in the sitting position. Patients undergoing epidural puncture at lower thoracic levels (T10-T12) received 25 mL of autologous blood, 15 mL and 18 mL were injected at spinal segments T5-T7 (mid-thoracic) and T2-T4 (upper- thoracic), respectively. Thoracic EBPs did not lead to immediate resolution of symptoms in 3 of 18 patients; one of them underwent early repetition with complete headache relief, one refused a second EBP, and one experienced partial resolution, followed by a recurrence, and then satisfactory improvement with a second high thoracic EBP. In long-term follow-up only 2 patients complained of symptoms or relapses. LIMITATIONS: Retrospective nature of the case series, single center experience. CONCLUSIONS: Performing thoracic-targeted EBPs as the preferred approach theoretically improves results with respect to those observed with lumbar EBPs. The immediate response was comparable with that of other reports, but the long-term success rate (90%) turned out to be very effective in terms of both quality of headache relief and very low incidence of recurrence.


Assuntos
Placa de Sangue Epidural/métodos , Espaço Epidural , Hipotensão Intracraniana/diagnóstico , Hipotensão Intracraniana/terapia , Vértebras Torácicas , Adulto , Idoso , Feminino , Cefaleia/diagnóstico , Cefaleia/etiologia , Cefaleia/terapia , Humanos , Hipotensão Intracraniana/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
15.
World J Gastroenterol ; 21(26): 8004-13, 2015 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-26185371

RESUMO

Although the perioperative bleeding complications and the major side effects of blood transfusion have always been the primary concern in liver transplantation (OLT), the possible cohesion of an underestimated intrinsic hypercoagulative state during and after the transplant procedure may pose a major threat to both patient and graft survival. Thromboembolism during OLT is characterized not only by a complex aetiology, but also by unpredictable onset and evolution of the disease. The initiation of a procoagulant process may be triggered by various factors, such as inflammation, venous stasis, ischemia-reperfusion injury, vascular clamping, anatomical and technical abnormalities, genetic factors, deficiency of profibrinolytic activity, and platelet activation. The involvement of the arterial system, intracardiac thrombosis, pulmonary emboli, portal vein thrombosis, and deep vein thrombosis, are among the most serious thrombotic events in the perioperative period. The rapid detection of occlusive vascular events is of paramount importance as it heavily influences the prognosis, particularly when these events occur intraoperatively or early after OLT. Regardless of the lack of studies and guidelines on anticoagulant prophylaxis in this setting, many institutions recommend such an approach especially in the subset of patients at high risk. However, the decision of when, how and in what doses to use the various chemical anticoagulants is still a difficult task, since there is no common consensus, even for high-risk cases. The risk of postoperative thromboembolism causing severe hemodynamic events, or even loss of graft function, must be weighed and compared with the risk of an important bleeding. In this article we briefly review the risk factors and the possible predictors of major thrombotic complications occurring in the perioperative period, as well as their incidence and clinical features. Moreover, the indications to pharmacological prophylaxis and the current treatment strategies are also summarized.


Assuntos
Coagulação Sanguínea , Transplante de Fígado/efeitos adversos , Embolia Pulmonar/etiologia , Tromboembolia/etiologia , Trombose Venosa/etiologia , Anticoagulantes/administração & dosagem , Anticoagulantes/efeitos adversos , Coagulação Sanguínea/efeitos dos fármacos , Testes de Coagulação Sanguínea , Humanos , Hemorragia Pós-Operatória/induzido quimicamente , Valor Preditivo dos Testes , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Embolia Pulmonar/prevenção & controle , Medição de Risco , Fatores de Risco , Tromboembolia/sangue , Tromboembolia/diagnóstico , Tromboembolia/prevenção & controle , Fatores de Tempo , Resultado do Tratamento , Trombose Venosa/sangue , Trombose Venosa/diagnóstico , Trombose Venosa/prevenção & controle
16.
Crit Care Med ; 43(8): 1559-68, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25821918

RESUMO

OBJECTIVES: We aimed to identify all treatments that affect mortality in adult critically ill patients in multicenter randomized controlled trials. We also evaluated the methodological aspects of these studies, and we surveyed clinicians' opinion and usual practice for the selected interventions. DATA SOURCES: MEDLINE/PubMed, Scopus, and Embase were searched. Further articles were suggested for inclusion from experts and cross-check of references. STUDY SELECTION: We selected the articles that fulfilled the following criteria: publication in a peer-reviewed journal; multicenter randomized controlled trial design; dealing with nonsurgical interventions in adult critically ill patients; and statistically significant effect in unadjusted landmark mortality. A consensus conference assessed all interventions and excluded those with lack of reproducibility, lack of generalizability, high probability of type I error, major baseline imbalances between intervention and control groups, major design flaws, contradiction by subsequent larger higher quality trials, modified intention to treat analysis, effect found only after adjustments, and lack of biological plausibility. DATA EXTRACTION: For all selected studies, we recorded the intervention and its comparator, the setting, the sample size, whether enrollment was completed or interrupted, the presence of blinding, the effect size, and the duration of follow-up. DATA SYNTHESIS: We found 15 interventions that affected mortality in 24 multicenter randomized controlled trials. Median sample size was small (199 patients) as was median centers number (10). Blinded trials enrolled significantly more patients and involved more centers. Multicenter randomized controlled trials showing harm also involved significantly more centers and more patients (p = 0.016 and p = 0.04, respectively). Five hundred fifty-five clinicians from 61 countries showed variable agreement on perceived validity of such interventions. CONCLUSIONS: We identified 15 treatments that decreased/increased mortality in critically ill patients in 24 multicenter randomized controlled trials. However, design affected trial size and larger trials were more likely to show harm. Finally, clinicians view of such trials and their translation into practice varied.


Assuntos
Cuidados Críticos/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Feminino , Fibrose/terapia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipotermia Induzida/mortalidade , Masculino , Estudos Multicêntricos como Assunto , Decúbito Ventral , Reprodutibilidade dos Testes , Projetos de Pesquisa , Respiração Artificial/métodos , Respiração Artificial/mortalidade , Ácido Tranexâmico/sangue
17.
Ann Surg Oncol ; 22(8): 2787-8, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25605516

RESUMO

BACKGROUND: Laparoscopic microwave ablation and portal vein ligation for staged hepatectomy (LAPS) is a new technique with a first laparoscopic step available in cases of unresectable right liver masses and inadequate future liver remnant (FLR). METHODS: In Step 1, laparoscopic right portal vein occlusion is performed with microwave ablation on the future transection plane and in the FLR. Step 2 consists of a totally laparoscopic right trisectionectomy. RESULTS: Duration of the Step 1 operation was 170 min, without the need for blood transfusions and intensive care unit admission. The postoperative liver volumetric computed tomography scan was performed on postoperative day 9 and revealed a satisfactory left hepatic hypertrophy (FLR 666 cm(3); FLR to body weight ratio 0.96; FLR increase 90.4 %; daily FLR hypertrophy 35 cm(3)/day). Duration of the Step 2 operation was 630 min (liver transection time 240 min). Blood loss was 700 cc, with no need for transfusion. The specimen was extracted through a 10-cm Pfannenstiel incision, and pathology revealed a tumor-free resection margin (R0). The patient was discharged on postoperative day 7 without complications (total hospital stay for Step 1 + Step 2: 10 days). CONCLUSIONS: Totally LAPS is a technically feasible and safe procedure. It could provide benefit in selected patients with primarily non-resectable liver cancer, making extreme liver surgery easy and safe in well-selected patients.


Assuntos
Ablação por Cateter/métodos , Neoplasias Colorretais/patologia , Hepatectomia/métodos , Neoplasias Hepáticas/cirurgia , Veia Porta/cirurgia , Humanos , Laparoscopia , Ligadura , Neoplasias Hepáticas/secundário , Masculino , Micro-Ondas/uso terapêutico , Pessoa de Meia-Idade , Carga Tumoral
18.
Transplantation ; 99(6): 1257-64, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25427166

RESUMO

BACKGROUND: Central pontine and extrapontine myelinolysis (CPM/EPM) are severe neurologic complications after liver transplantation. METHODS: The present work retrospectively evaluated single-center prevalence of CPM/EPM and associated risk factors: cause of liver disease, hepatic encephalopathy, preoperative, intraoperative, and perioperative blood components use, serum levels, and variation of Na, Cl, and K and immunosuppression were compared between CPM/EPM patients and control group of transplanted patients without neurologic complications. RESULTS: Among 997 transplants, CPM/EPM were diagnosed in 11 patients (1.1%), of whom four were CPM, one was EPM, and six were associated CPM and EPM. Control group consisted of 44 transplanted patients. Central pontine and extrapontine myelinolysis patients experienced higher intraoperative and perioperative serum Na/24 hr variations compared to controls (16.69 ± 5.17 vs. 9.8 ± 3.4 mEq/L, P = 0.001). Maximum peak of intraoperative or perioperative serum Na was significantly higher in patients compared to controls (151.5 ± 3.3 vs. 140.8 ± 6.2 mEq/L, P ≤ 0.001), but no difference in preoperative serum Na was detected. Three patients presented hypernatremia as isolated risk factor. CONCLUSION: Extrapontine myelinolysis can be found isolated or associated with CPM in up to two of three liver transplanted patients with myelinolysis. A marked variation of perioperative serum Na remains the main risk factor even in patients without preexisting hyponatremia; however, isolated hypernatremia may be solely responsible in some cases.


Assuntos
Transplante de Fígado/efeitos adversos , Mielinólise Central da Ponte/etiologia , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Hipernatremia/sangue , Hipernatremia/complicações , Hiponatremia/sangue , Hiponatremia/complicações , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mielinólise Central da Ponte/sangue , Mielinólise Central da Ponte/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Sódio/sangue
19.
Surgery ; 156(6): 1605-12; discussion 1612-3, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25456960

RESUMO

BACKGROUND: Acupuncture is a safe and well-tolerated treatment for pain relief. Previous studies supported the effectiveness of several acupuncture techniques for postoperative pain. The aim of this randomized, controlled trial was to evaluate the efficacy of acupuncture in reducing pain after thyroid surgery. METHODS: We randomized 121 patients to a control group (undergoing only standard postoperative analgesic treatment with acetaminophen) and an acupuncture group, undergoing also either electroacupuncture (EA) or traditional acupuncture (TA). Pain was measured according to intraoperative remifentanil use, acetaminophen daily intake, Numeric Rating Scale (NRS), and McGill Pain Questionnaire on postoperative days (POD) 1-3. RESULTS: Acupuncture group required less acetaminophen than controls at POD 2 (P = .01) and 3 (P = .016). EA patients required less remifentanil (P = .032) and acetaminophen than controls at POD 2 (P = .004) and 3 (P = .008). EA patients showed a trend toward better NRS and McGill scores from POD 1 to 3 compared with controls. EA patients had a lower remifentanil requirement and better NRS and McGill scores than TA patients. No differences occurred between TA patients and controls. CONCLUSION: Acupuncture may be effective in reducing pain after thyroid surgery. EA is more useful; TA achieves no significant effects.


Assuntos
Terapia por Acupuntura/métodos , Dor Pós-Operatória/terapia , Tireoidectomia/efeitos adversos , Adulto , Idoso , Analgésicos/uso terapêutico , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Satisfação do Paciente/estatística & dados numéricos , Estudos Prospectivos , Valores de Referência , Índice de Gravidade de Doença , Método Simples-Cego , Estatísticas não Paramétricas , Tireoidectomia/métodos , Resultado do Tratamento
20.
Curr Opin Crit Care ; 20(4): 411-9, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24979712

RESUMO

PURPOSE OF REVIEW: Major improvements in perioperative care and immunobiology have not abated the risk for severe pulmonary complications after solid-organ transplantation. The aim of this study is to update information on infectious and noninfectious pulmonary complications after solid-organ transplantation, addressing epidemiology, risk factors, diagnostic workup, and management. RECENT FINDINGS: Infectious and noninfectious postoperative pulmonary complications depend on the grafted organ and the anatomical site of transplantation. Kidney transplants have the lowest incidence of pulmonary complications, the highest being reported for heart, lung, and liver recipients. Respiratory tract infections, ranking first in heart and lung transplants and second in liver recipients, are a common cause of mortality. Risk factors include end-stage organ disease, comorbidities, perioperative procedures, and graft function. Factors specific for infections are timeline, state of immunosuppression, and graft dysfunction. Nosocomial multi-drug resistant pathogens are frequently responsible for the most severe infections. Aggressive diagnostic workup, early and broad empiric antiinfective therapy, and deescalation policy are the mainstays of their management. The role of intraoperative protective ventilation is under scrutiny. SUMMARY: Pulmonary complications after solid-organ transplantation, and particularly infections, are able to compromise the extremely good results of the transplant procedures. Solid-organ transplantation recipients challenge the ICU physician with unique aspects of their post-transplant course, adding, in an already critical patient, the immunosuppressed state and the quality of the functional recovery of the graft.


Assuntos
Pneumopatias/etiologia , Transplante de Órgãos , Complicações Pós-Operatórias , Humanos
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