meld score a reliable outcome predictor in living donor liver transplantation?

In patients undergoing orthotopic liver transplantation [OLT], some studies have shown that a higher preopcrative MELD score is associated with higher morbidity and mortality [Saab et aL 2003]. Other studies also suggest that higher MELD scores are associated with increased inlraoperativc risks [Xia et al 2008]. to evaluate the impact of preoperative MELD status on metabolic, electrolyte and haemodynamic changes during living donar liver transplantation, and consequently on outcome and for right choice of candidate who will get greatest benefit from transplantation. After approval iron- ethical committee and a written consent from every patient a prospective observational study including 40 patients scheduled for living donor liver transplantation in Wady El nile hospital. Patients classified according to MELD score into group 1 [Gl] with score <25 and group2 [G2] > 25. Haemodynamic, metabolic and electrolytes data collected during the three phases: pro anhepatic, anhepatic and post reperfusion phase and follow up for 1[st] post operative week then two years mortality. G2 associated with significant intraoperative haemodynamic disturbances in all stages compared to Gl in the form of lower mean arterial blood pressure, lower systemic vascular resistance, higher pulmonary vascular resistance, and higher cardiac output. Also there were more intraoperative metabolic and electrolyte disturbances as there were more acidosis, lower standard bicarbonate values, more base deficits, more negative anion gap and strong ion difference, higher serum potassium level, poor intraoperative glycemic control and much higher blood lactate level. Also there were higher early mortality in G2 8 cases [40%] while 3 cases [15%] in GL 2 years mortality in Gl 5 cases [25%] while 10 cases [50%] in G2,, time of ICU stay was 5.1 days in G1 and 7 days in G2 time of hospital stay was 21.6 days in Gl and 26.2 days in G2 High MELD score patients associated with more intraoperative haemodynamic, metabolic and electrolyte disturbances, longer postoperative ICU and hospital stay and higher mortality

Comparison between Nalbuphine and propofol for Treatment of intrathecal morphine-induced pruritus after cesarean section

Intrathecal opioids are frequently used in management of postoperative pain, but may be associated with many adverse effects such as pruritus, nausea, vomiting, urinary retention, and respiratory depression, which may limit their use. Our study was done to compare between nalbuphine [a mixed opioid agonist antagonist] and propofol [2-6 di-isopropylphenol] in treating intrathecal morphine-induced pruritus after cesarean delivery. It included one hundred forty one parturients undergoing elective cesarean section with spinal anesthesia and post-operative analgesia by intrathecal morphine [0.3 mg]. Ninty four parturients were reported to have moderate to severe pruritus. Without pre-medications, all women were hydrated with 500 to 1000 ml of normal saline before intrathecal injection of 7.5-10 mg of bupivacaine for spinal anesthesia and morphine 0.3 mg for postoperative pain control. Heart rate, mean blood pressure, respiratory rate and oxygen saturation were monitored. The degree and onset of pruritus were also recorded. Those parturients whose pruritus scores was >/= 3 or those who requested antipruritic treatment were assigned to receive either 3mg nalbuphine IV, 20mg propofol IV or placebo. The degree of success was reported when pruritus score decreased to 1 or 2 after treatment and then women were evaluated every 15 minutes for up to 4 hours to determine the duration of antipruritic response. The patients who continued to have pruritus scores >/= 3 were considered treatment failure after only a single dose of the study medicine. Any side effects from spinal anesthesia or from the drugs used were recorded. we were able to demonstrate that the success rate after treatment with 3 mg of nalbuphine was significantly greater than with 20 mg of propofol. Among the successfully treated patients, [8%] in the Nalbuphine group and [5.3%] in the Propofol group reported the recurrence of moderate to severe pruritus [pruritus score >/= 3] within 4 hours after administration of the study drug. Among all the treated patients, [21.9%] in the Nalbuphine group and [40.6%] in the Propofol group reported failure of success [moderate to severe pruritus [pruritus score >/= 3]] within 15 minutes after administration of the study drug. our study showed that nalbuphine [3 mg] was superior to propofol [20 mg] in the treatment of intrathecal morphine induced pruritus after cesarean delivery

Preeclampsia: the effect of intravenous fluid preload on vasoactive peptide secretion during caesarean section under spinal anaesthesia

We followed the haemodynamic parameters and determined the peripheral venous levels of ANF, ET-1 and NO before and after, intravenous volume preload of I litre Ringer's solution, followed by a further load of the same volume under spinal anaesthesia in 15 healthy and I5pre-eelamptic women. Blood pressure was decreased significantly in both groups after spinal anaesthesia and such decrease was less in the preeclamptic group. The baseline concentration of ANP was higher in preeclamptic women than in normal pregnancy women. It increased significantly in both groups after the JSI infusion, the.2 nd infusion and after delivery. The CVP increased more during the preload period in the preeclamptic group than in healthy women. The increase in the concentrations of ANP correlated significantly with the increase in CVP in total study group. The baseline concentration of ET-1 was higher in preeclamptic women than in healthy women, it decreased significantly in both groups after the first and second infusions. The plasma concentrations of ET-1 increased significantly in the cord sample both groups. NO increased more in the preeclamptic group during the preload period in healthy women while the same increase was noted after the second infusion in groups. After delivery NO concentration in the cord sample was higher in the preeclamptic group than in healthy women. There was no significant difference in the number of neonates with Apgar score < 7, NACS and the parameters of arterial blood gas between the two groups. We conclude from this study that the release of ANP increases in response to a rapid intravenous infusion of a crystalloid solution during elective Caesarean delivery which is exaggerated in women with preeclampsia. This may help in the vasculatory adaptation to the volume load by increasing its capacity. The increase ANP release was not sufficient to decrease maternal arterial blood pressure, but may counteract vasospasm locally in the maternal and uteroplacental circulation

Sevoflurane versus isoflurane in normal and pre-eclamptic parturients undergoing cesarean delivery

One hundred and twenty pregnant women were randomly assigned to receive either isoflurane two groups] or sevoflurane [two groups] using on open [non-blinded] study design. Anesthesia was maintained with either isoflurane 0.5% end tidal or sevoflurane 1% end tidal in combination with nitrous [N2O] 50% in oxygen. Liver functions, kidney functions, complete blood count and coagulation profile were measured and recorded. Pharmacokinetic study included serum inorganic fluoride concentration and kinetics of serum inorganic fluoride. Also, blood pressure, heart rate, central venous pressure [CVP] monitoring, ECG, estimation of intra-operative blood loss, uterine tone, recovery profile and urine in 24 hours were also studied. Infant outcome was also evaluated by Apgar score, neurologic adaptive capacity score [NACS], umbilical artery blood gas, acid base status and serum fluoride level. From the results obtained, it was concluded that sevoflurane appears to be similar to isoflurane with a few exceptions. It appears similar to isoflurane in its effect on regional blood flows including the hepatic and renal circulation. The use of sevoflurane resulted in faster emergence than after isoflurane. The high serum fluoride levels associated with administration of sevoflurane anesthesia were not dangerous, because it did not reach the level that cause nephrotoxicity. Neonatal outcomes were similar after anesthesia with either isoflurane or sevoflurane. So, sevoflurane 1.0% is a suitable alternative to isoflurane 0.5% for maintenance of anesthesia in such cases, but in this era of cost containment and rationing of health resources, it remains to be seen whether sevoflurane will supplant isoflurane for obstetrical anesthesia

Effect of midazolam/fentanyl infusion on haemodynamic and metabolic responses during short surgical procedures

Midazolam was used in combination with fentanyl as total intravenous anesthesia for twenty patients undergoing short surgical procedures; fentanyl [1.5 ug/kg] was given intravenously. Three minutes later, midazolam was administered started by bolus dose of 0.3 mg/kg, followed by drip infusion of 0.25 mg/kg/h. Patients were oxygenated by 100% O2 face mask during the procedures. The hemodynamics and metabolic responses [serum cortisol, lactate, pyruvate and blood glucose changes] were followed preoperatively, intra and postoperatively. Although the hemodynamic parameters [systolic, diastolic and mean blood pressure, heart rate and rate pressure product] showed significant changes, they were not of apparent importance. Insignificant increase in blood glucose concentration was seen following incision; but maximum significant concentration was measured after two hours. From induction in the early postoperative period, serum cortisol concentration significantly increased after induction and during surgery then after 24 hours serum cortisol and glucose returned to pre-induction values. Serum lactate significantly decreased until 24 hours after induction, but serum pyruvate increased significantly at skin incision and during operation; but after 24 hours it returned to pre-induction values. In all patients, good operating conditions were produced and patient's acceptance was high. It was concluded that midazolam infusion in combination with fentanyl may be useful technique in short procedures without inhibiting adrenal steroid release or producing cardiorespiratory instability