Liver transplantation and aortic valve replacement

Surgical procedures involving heart and liver are rare and have been limited to either combined heart and liver transplantation or coronary artery bypass graft surgery [CABG] or aortic valve surgery and orthotopic liver transplantation [OLT]. Aortic valve replacement [AVR] and pulmonary valve vegetectomy for bacterial endocarditis after OLT have also been reported. There are only five cases with aortic stenosis and cirrhosis reported to have combined AVR and liver transplantation. In the presence of cirrhosis, AVR has a significant risk for mortality because of bleeding from coagulopathy, renal failure, infection, and poor post-operative wound healing. Herein, we report on a case and management analysis of combined sequential AVR, and OLT in a 40-year-old cirrhotic man with Child and MELD score of C and 29, respectively. Echocardiography detected severe aortic insufficiency [AI] with enlarged left ventricle. Due to severe AI, the cardiologist recommended AVR prior to transplantation. The patient underwent metallic AVR. 4 months later, he received OLT. Both operations were successful and uneventful. Prioritizing AVR before OLT was successful in this patient. However, each patient must be evaluated individually and multiple factors should be assessed in pre-operation evaluation

Post-reperfusion syndrome and outcome variables after orthotopic liver transplantation

Post-reperfusion syndrome [PRS] is an important during liver transplantation. We studied the occurrence and severity of PRS in patients who underwent orthotopic liver transplantation [OLT] to investigate how PRS was correlated to clinical variables and outcomes. We retrospectively recorded intra- and peri-operative data for 184 adult patients who received cadaveric OLT during a 3-year period from 2005 to 2008. Patients were divided into two groups according to the severity of PRS: Group 1 [mild or no PRS] comprised 152 patients; and group 2 [significant PRS] consisted of 32 patients. There were no significant differences in demographic and pre-operative data between groups. Group 2 had more total blood loss than group 1 [p=0.036], especially after reperfusion [p=0.023]. Group 2 required more packed red cell transfusions [p=0.005], more fresh frozen plasma [p=0.003] and more platelets [p=0.043] than group 1. Fibrinolysis was more frequent in group 2 [p=0.004]. hospital stay in group 2 was significantly longer than in group 1 [p=0.034], but the frequencies of other outcomes including infection, re-transplantation, dialysis, rejection and extended donor criteria did not differ significantly between groups. Bleeding, blood transfusion and fibrinolysis occurred more often in the group of severe PRS after reperfusion. Although postoperative complications like rejection, infection and the dialysis rate were not significantly different in the two groups, hospital stay was more prolonged in the group with severe PRS

Factors affecting early and late extubation in liver transplant patients

Tracheal extubation is a critical stage and expensive practice in patients undergoing major operations such as liver transplantation. This study was carried out to determine factors affecting extubation time in liver transplant patients. From 2003 to 2006, all patients undergoing liver transplantation in Nemazee Hospital affiliated to Shiraz University of Medical Sciences were enrolled. All patients were anesthetized identically and the time of extubation was based on standard protocol of extubation. The patients were divided into two groups of extubated after admission in less [Group 1] and more than [Group 2] four hours. The effect of 19 pre and post operative factors on extubation was also evaluated. Two hundred patients [Group 1=121; Group 2=79] entered the study. A significant correlation was noticed for bleeding during operation, abnormal blood pressure more than 30 minutes at the end of surgery and duration of operation. A rise in extubation time was observed when duration of surgery increased. In ICU, 37 patients needed reintubation among them 23 were in Group 2 and 14 in Group 1. The most common causes of reintubation were insufficient oxygenation, repeated laparatomy and decrease in consciousness level. The mean days of ICU staying in early and late extubation groups were 4.16 and 6.04 days [p=0.001]. It seems that duration of surgery, bleeding during operation and an abnormal blood pressure may delay the time of extubation. An early extubation may result into a decrease in duration of ICU admission too

Assessment of a low dose of IV midazolam used orally for conscious sedation in pediatric dentistry

Midazolam is preferably used in pediatric dentistry for quick onset of action and recovery. The aim of this prospective, observer-blind and placebo-controlled study was to assess the efficacy of a low dose of oral midazolam in modification of the behavior of young pediatric dental patients. Forty children aged 3 to 5 years who displayed ratings 1 or 2 on the Frankl Scale and were healthy by the American Society of Anesthesiologists-I status were randomly divided into two experimental and control groups of 20 each. All children required pulpotomy and restoration of D and E teeth and received either 0.25mg/kg of a 15mg/3ml IV midazolam mixed in black cherry syrup or the syrup alone. Subjects were continuously observed and monitored with pulse oximetry. Houpt's Behavioral Ratings was used to determine the overall behavior, the degree of crying and movement during treatment. Mann-Whitney U test was used for statistical analysis. Patients who received 0.25mg/kg of the prepared oral midazolam significantly behaved better during treatment than the placebo controls [P<0.05]. In comparison with the placebo group, reduced movement and crying were observed in the midazolam group [P<0.05]. No adverse effects were observed and treatments were completed successfully. A low dose of 0.25mg/kg of a 15mg/3ml IV midazolam mixed in black cherry syrup was found to be effective in conscious sedation of young pediatric dental patients