Live donor hepatectomy for liver transplantation in Egypt: lessons learned

To retrospectively review anesthesia and intensive care management of 145 consented volunteers subjected to right lobe or left hepatectomy between 2003 and 2011. After local ethics committee approval, anesthetic and intensive care charts, blood transfusion requirements, laboratory data, complications and outcome of donors were analyzed. One hundred and forty-three volunteers successfully tolerated the surgery with no blood transfusion requirements, but with a morbidity rate of [50.1%]. The most frequent complication was infection [21.1%] [intraabdominal collections], followed by biliary leak [18.2%]. Two donors had major complications: one had portal vein thrombosis [PVT] treated with vascular stent. This patient recovered fully. The other donor had serious intraoperative bleeding and developed postoperative PVT and liver and renal failure. He died after 12 days despite intensive treatment. He was later reported among a series of fatalities from other centers worldwide. Epidural analgesia was delivered safely [n=90] with no epidural hematoma despite significantly elevated prothrombin time [PT] and international normalization ratio [INR] postoperatively, reaching the maximum on Day 1 [16.9 +/- 2.5 s and 1.4 +/- 0.2, P < 0.05 when compared with baseline]. Hypophosphatemia and hypomagnesemia were frequently encountered. Total Mg and phosphorus blood levels declined significantly to 1.05 +/- 0.18 mg/dL on Day 1 and 2.3 +/- 0.83 mg/dL on Day 3 postoperatively. Coagulation and electrolytes need to be monitored perioperatively and replaced adequately. PT and INR monitoring postoperatively is still necessary for best timing of epidural catheter removal. Live donor hepatectomy could be performed without blood transfusion. Bile leak and associated infection of abdominal collections requires further effort to better identify biliary leaks and modify the surgical closure of the bile ducts. Donor hepatectomy is definitely not a complication-free procedure; reported complication risks should be available to the volunteers during consenting

Prevalence of Multi-Drug resistant pseudomonas Spp. and acinetobacter Spp. causing nosocomial infection in intensive care unit [ICU] of national liver institute

Non-fermenting gram negative bacilli including Pseudomonas aernginosa, Stenotrophomonas maltophilia and Acinetobacter spp. have been implicated in a variety of nosocomial infection particularly in Intensive Car Units [ICUs]. This study aimed to overview the problem of multidrug resistant Pseudomonas spp an Acinetobacter spp causing nosocomial infections in ICUs in National Liver Institute and to determine the risk factors predisposing to these infections, also to assess the occurrence of ES beta ls and M beta Ls among these isolates. The study included 160 nosocomially infected patients [97 males and 63 females]. Also,20 hospital staff who were in close contact to ICU patients and 40 environment and equipment samples from the ICU. Bacterial culture and identification were carried out using standard microbiological methods. The antibiotic susceptibility was tested using the disc diffusion methods, also gram negative isolates were tested for ES beta Ls and M beta L production by disk diffusion method, double disk synergy test and E test [for MBL]. Our results revealed that NF gram negative isolates represented 18.75% of nosocomial isolates. Pseudomonas spp was 15.6%, Acinetobacter spp was 2.1% and Stenotrophomonas maltophilia was 1.04%. They were frequently isolated from cases with ventilator associated pneumonia [VAP]. All isolates were resistant to ampicillin and augmentin, They were highly sensitive to gentamycin [Pseudomonas spp 80.6%, Acinetobacter spp 80% and S. maltophilia 100%]. They were highly resistant to ceftriaxone [Pseudomonas spp 77.8%, Acinetobacter spp 80% and S.maltophilia 50%], ceftazidime[Pseudomonas spp 80.6%, Acinetobacter spp 100% and S.maltophilia 100%], Rates of resistant to Imipenem were[Pseudomonas spp 61.1%, Acinetobacter spp 80% and S.maltophilia 50%]. ES beta L +ve Pseudomonas spp. and Acinetobacter spp. detected by disk diffusion method were 38.9% and 40% respectively, and confirmed by double disk synergy tests were 25% and 40% respectively. M beta L was produced by 61.1% of Pseudomonas isolates and 80% of Acinetobacter isolates detected by disk diffusion and DDT, while E test detected the presence of M beta L in 52.8% of Pseudomonas isolates and 60% of Acinetobacter isolates. In conclusion non-fermenting Gram-negative bacilli including Pseudomonas spp, Acinetobacter spp and Stenotrophamoneas maltophilia were important causes of nosocomial infections in ICUs,particularly VAP. Most of these isolates were multidrug resistant and producers of ES beta L and M beta L

Aprotinin versus tranexamic acid in cirrhotic patients undergoing hepatic surgery

Patients with liver cirrhosis have complex hemostatic dysfunction characterized by impaired clotting factor synthesis, thrombocytopenia and accelerated fibrinolysis. Pharmacological management has been advocated to decrease bleeding and transfusions during major hepatic surgery, with the use of either aprotinin or tranexamic acid. In the present study, aprotinin was given in moderate doses to 10 patients and tranexmaic acid was given to another 10 patients compared with control group. Hemostasis was significantly better preserved after aprotinin treatment [blood loss of 373 ml in the aprotinin group, 524 ml in tranexamic acid group versus 956 ml in the control group]. Platelets were better preserved in aprotinin and tranexamic acid groups. Fibrinolysis was significantly reduced in aprotinin and tranexamic acid groups, where fibrinogen level was significantly reduced in the control group [206.8 mg/dl, 184 mg/dl at 4 and 6 hours intraoperatively] and FDPs were significantly increased in the control group [FDPs changed from 4.8 micro g/dl to 26 micro g/dl during surgery]. We conclude that prophylactic use of either aprotinin [in moderate doses] or tranexamic acid is equivocal and is mandatory in the operative management of hepatic resection

Medicolegal aspect of voice analysis in prolonged endotracheal intubation versus laryngeal mask airway

Voice print analysis has been utilized in many different situations. The present study was designed to compare the changes of voice analysis in the first 24 hours after insertion of laryngeal mask airway [LMA] with those produced by endotracheal intubation. By using spectrum analyzer, we measured the frequency and the intensity level before and after anaesthesia at different intervals up to 24 hours from full recovery. There were significant differences between LMA and endotracheal intubation in the 2 variables [frequency and intensity]. Also the result demonstrated that both LMA and endotracheal intubation affected the voice print, but LMA caused little vocal changes than tracheal intubation and versus 24 hours after full recovery. The study suggest that the voice print must not be taken except after 24 hours from general anaesthesia