Anesthesia for liver transplantation: the experience of the University of Bologna in the MELD era.

AIM: The hepatic cirrhosis is associated with an important cardiovascular alterations. In this report, we review our transplant center experience with liver transplantation in the Model for End-Stage Liver Disease (MELD) era, in particular this study investigate the relationship between severity of liver disease assessed by MELD score and postoperative events. METHODS: Our retrospective review was performed on 242 cirrhotic patients underwent liver transplanation at the Department of Surgery and Transplantation of the University of Bologna. Biochemical and hemodynamic variables were evaluated by Swan-Ganz catherization. Dindo's classification of postoperative complications was used for the evaluation of postoperative course. RESULTS: Morbidity occurred in 158 patients (65.2%) and 13 patients died during the hospital stay. Considering the highest grade of complication occurred, non life-threatening complications occurred in the 47.9% of cases (116 patients) and life-threatening complications, excluding patient death, in 17.3% (42 patients). Patients with MELD >30 showed a longer ICU stay, tracheal intubation and in-hospital stay. CONCLUSION: In conclusion MELD score is tightly related to postoperative complications.

Recovery and cryopreservation of epididymal sperm of plains bison (Bison bison bison) as a model for salvaging the genetics of wood bison (Bison bison athabascae).

The objective of this study was to optimize recovery and cryopreservation of epididymal sperm from plains bison, as a model for wood bison. In Phase 1, cauda epididymides were recovered from bison (n = 14) immediately after slaughter, minced and incubated in Sp-TALPH buffer for 3 h at 36 degrees C. The resulting sperm suspensions were cryopreserved in Triladyl, using a protocol for bovine semen. In Phase 2, epididymal sperm were cryopreserved in either Triladyl or Andromed. The mean (+/-SD) estimated number of sperm recovered was 468 +/- 207 x 10(6). There was an increase (p < 0.05) in the proportion of sperm with normal morphology between initial recovery and after extension (52.4 +/- 4.6 vs 69.7 +/- 2.4%), with a concurrent decrease (p < 0.05) in the proportion of sperm with distal droplets. Median values for progressively motile sperm in post-thaw samples (60%) were lower (p < 0.05) than that after extension or after chilling (70% for both). The mean percentages of viable sperm and of sperm with an intact acrosome were lower (p < 0.05) for frozen-thawed samples (38.7 +/- 2.8 and 85.2 +/- 1.1) compared with extended (66.2 +/- 2.2 and 92.4 +/- 0.9) or chilled (63.7 +/- 2.5 and 90.0 +/- 1.0) samples. Rates of cleavage, morulae and blastocyst production were not significantly different for chilled (70.9, 38.7 and 8.0%) vs post-thaw sperm (73.0, 46.0 and 6.3%). There was no significant difference between extenders for most sperm characteristics. In conclusion, we developed a functional protocol for the recovery and cryopreservation of epididymal sperm from plains bison, which may have implications for the genetic preservation of wood bison.

Hyperdynamic circulation in cirrhosis: predictive factors and outcome following liver transplantation.

BACKGROUND: Liver cirrhosis is associated with a hyperdynamic circulation (HC). In this observational study, we aimed to investigate the predictive factors of HC, its impact on intraoperative hemodynamic and postoperative outcome, early ICU and in-hospital mortality, in cirrhotic patients undergoing orthotopic liver transplantation (OLT). METHODS: Two hundred and forty-two patients with cirrhosis undergoing cadaveric OLT were included. Before starting the transplant procedure and under general anesthesia, a pulmonary artery catheter was introduced to assess hemodynamic parameters. The baseline assessment was carried out approximately 30 minutes after the catheter placement and repeated during the anhepatic phase, 10 minutes after the reperfusion and at the end of surgery. The patients were divided into two groups: in group 1 the patients had SVR>900dynes s-1 m-2 cm-5, in group 2 SVR ≤900 dynes s-1 m-2 cm-5. RESULTS: Eighty-two patients (33%) presented severe HC. In multivariate analysis 2 factors were associated with the occurrence of HC: beta-blockers use (Exp [B]=4.42 (95% CI 1.18-17); P=0.001, [34% and 12% in groups 1 and 2, P<0.001, respectively]) and model for end-stage liver disease (MELD) score (Exp [B]=1.066; 95% CI=1.025-1.109; P=0.001). CONCLUSION: MELD score was an independent predictor of HC, and beta-blockers resulted associated with lower incidence of HC in cirrhotic patients undergoing cadaveric OLT. Intraoperative HC correlates with hemodynamic alterations, requiring more blood products and vasopressor use, this may increase the risk of renal failure, early ICU death and in-hospital mortality.

Long-lasting beneficial effects of periradicular injection of meloxicam for treating chronic low back pain and sciatica.

BACKGROUND: Chronic low back pain (LBP) and sciatica can occur without obvious structural causes and are often resistant to conventional analgesic drugs. The effect of periradicular injection of meloxicam on LBP with or without a radicular component was assessed. A secondary objective of this prospective observational study was to assess the effect of meloxicam on functional recovery. METHODS: Seventy-two patients (30 men, 42 women) with LBP and/or sciatica were followed for 90 days to six years after injecting 10 mg meloxicam in 10 mL saline at each of the involved dermatomal levels. A standard verbal rating scale (VRS) from 0=no pain to 10=severe pain was used for assessing LBP before the injection of meloxicam (at baseline) and at 1, 5, 10, 30 and 60 min, and 1, 5, 15, 30 and 90 days intervals after the injection. The meloxicam injection was repeated only if the VRS score remained >3. Rescue analgesic requirements and functional activity levels were also assessed from 30-90 days after the last injection of meloxicam. RESULTS: The mean baseline LBP score was 8.60 ± 1.50 (SD) despite the use of multi-modal analgesic regimens (NSAIDs, glucocorticosteroids, paracetamol, oral opioids, gabapentanoid compounds, epidural or periradicular steroid and/or local anesthetics) as well as laser treatments and physical therapy. The majority of patients reported that their pain intensity decreased by ~50% 1-2 min after the meloxicam injection was completed. Thirty-six patients (50%) required no further injections, 25 patients (35%) required a second injection after seven days, and 11 patients (15%) required a total of three injections. After the meloxicam treatment(s), only 10 patients (14%) required "rescue" analgesia with oral NSAIDs. All patients were able to increase their level of functional activity after the meloxicam treatment(s). CONCLUSION: Periradicular injections of meloxicam (10 mg) appear to be a useful alternative to opioid and non-opiod analgesics for patients with intractable LBP due to nerve root inflammation.

Soft tissue depression at the iliac crest prominence: a new landmark for identifying the L4-L5 interspace.

BACKGROUND: One of the most common approaches to identifying the L4-L5 interspace is using the iliac crest as a landmark. We propose a new landmark to identify the L4-L5 interspace based on the soft tissue depression palpable at the iliac crest prominence. The aim of this study was to assess the reliability and time saving when using this new landmark compared to using the iliac crest to perform a lumbar plexus block. METHODS: Fifty-four patients scheduled for lower limb surgery were randomly allocated to have a lumbar plexus block performed using the iliac crest (Chayen's approach) or the soft tissue depression (Borghi's approach). The landmarks for both approaches were drawn on each patient prior to randomization (N.=27 per group). All the blocks were performed by an anesthesiologist familiar with both techniques using a nerve stimulator and 30 mL of 0.5% levobupivacaine. The time to achieve successful needle placement and the number of needle re-directions, as well as the onset time for the sensory and motor blockade, were recorded. RESULTS: All the blocks using Borghi's approach were performed successfully. With the Chayen's approach, there were 5 needle placement failures. The mean times to onset of a successful block after injection of the local anesthetic did not differ between the two groups: 17.8±3.9 min for the Chayen vs. 15.9±2.4 min for the Borghi's approach (P=0.14). However, the mean time to achieve correct needle placement was 7.6±3.2 min with the Chayen's approach compared to 5.1 (±2.6 SD) min with the Borghi's approach (P<0.01). The Chayen's approach also required a significantly higher median number of needle redirections (2 [inter-quartile range (IQR): 0-4] vs. 0 [IQR: 0-4], P<0.01). In obese patients (BMI ≥30 kg/m(2)), the mean placement time was 10.5±1.7 min vs. 4.8±2.1 min (P<0.01), and median number of needle re-directions was 2.5 (IQR: 2-3) vs. 0.5 (IQR: 0-3) (P=0.04), with the Chayen and Borghi's approach, respectively. CONCLUSION: Use of the palpable soft tissue depression at the iliac crest prominence for performing a lumbar plexus block offered several potential advantages over the standard inter-iliac crest approach.