Abdominal compartment syndrome: an underrated complication in pediatric kidney transplantation.

The transplantation of a large kidney in small children can lead to many complications, including an underrated complication known as abdominal compartment syndrome (ACS), which is defined as intra-abdominal pressure (IAP)≥20 mm Hg with dysfunction of at least one thoracoabdominal organ. Presenting signs of ACS include firm tense abdomen, increased peak inspiratory pressures, oliguria, and hypotension. Between June 1, 1985, and September 30, 2013, our center performed 420 kidney transplants (deceased/living related donors: 381/39) in 314 pediatric recipients (female/male: 147/167). ACS occurred in 9 pediatric patients (weight<15 kg) who received a large kidney from adult donors. In 1 case, the patient underwent abdominal decompression with re-exploration and closure with mesh in the immediate postoperative period. In a second case, the patient developed a significant respiratory compromise with hemodynamic instability necessitating catecholamines, sedation, and assisted ventilation. For small children transplanted with a large kidney, an early diagnosis of ACS represents a critical step. From 2005 we have measured IAP during transplantation via urinary bladder pressure, and immediately after wound closure we use intraoperative and postoperative duplex sonography to value flow dynamics changes. We recommend that bladder pressure should be routinely checked in small pediatric kidney recipients who are transplanted with a large graft.

Impact of Model for End-Stage Liver Disease score on transfusion rates in liver transplantation.

BACKGROUND: Liver transplantation (OLT) can entail a high risk of blood loss requiring transfusions, which increase morbidity and mortality. In recent years many efforts have been spent to improve the surgical and anesthetic management to decrease transfusion rates during OLT. Preoperative predictors for transfusion in OLT, remain uncertain. METHODS: We retrospectively reviewed the 219 OLT performed from 2005 to 2011 focusing on blood product (BP) transfusions. Statistical analysis sought the impact of transfusions on OLT outcomes to identify possible independent predictors of higher BP requirements. RESULTS: The 1- and 3-year survival rates were 86.6% and 76.45% for patients and 81.0% and 71.8% for grafts respectively. The mean intra- and perioperative red blood cell (RBC) transfusion rates were 12.3 ± 11.7 U and 15.5 ± 13.0 U respectively. A statistical analysis demonstrated a significant influence of BP transfusion on post-OLT complications and survivals. Multivariate logistic regression analysis showed the Model for End-Stage Liver Disease (MELD) score to be the only independent predictor of perioperative RBC transfusions. CONCLUSIONS: Our results confirmed the link between intra- and perioperative transfusions and outcome of OLT patients. MELD score resulted the only independent variable associated with increased perioperative RBC transfusions.

Renal transplant compartment syndrome: a case report.

An unusual case of early double kidney transplant dysfunction due to abdominal compartment syndrome is herein reported. A 62-year-old woman on peritoneal dialysis underwent dual kidney transplantation. The grafts were positioned extraperitoneally in both iliac possae using standard techniques. Surgical procedures and immediate postoperative period were uneventful. The urine output was immediate and the creatinine decreased, but in a few days she developed severe ascites with reduced urine output, increased creatinine, and progressive changes on Doppler ultrasound. The patient underwent paracentesis: the kidney function recovered as well as the Doppler ultrasound. Kidney biopsy was negative for rejection or renal pathology. Graft dysfunction was related to the presence of ascites. A catheter inserted in the abdomen measured intra-abdominal pressure (IAP) of 14 mm Hg. IAP correlated with renal function showing that IAP probably explained renal flow modifications.

Introducing ultrasound-guided vein catheterization into clinical practice: A step-by-step guide for organizing a hands-on training program with inexpensive handmade models.

INTRODUCTION: Central vein catheterization (CVC) plays a central role in hospital patient management. Compared with the use of traditional anatomical landmarks, ultrasound-guidance is associated with higher CVC success rates, fewer complications, and more rapid central venous access. The use of US-guided CVC in clinical practice has not become widespread, largely because anesthesiology and general surgery residents receive limited training in this technique. To increase the use of US-guided CVC in our surgical department, we organized a hands-on training program based on the use of handmade models. METHODS: Three different models were constructed using plastic food-storage containers, segments of rubber tourniquet and silastic tubing (to simulate vessels), and agar gelatin. RESULTS: The hands-on training course allowed progressive acquisition of the basic hand-eye coordination skills necessary for performing US-guided venipuncture. The overall cost for each model was less than €5.00. DISCUSSION: The models described in this report are useful tools for teaching US-guided CVC. Thanks to their low-cost, they can be widely used to facilitate the introduction of this technique in clinical practice.

Medical report type in liver transplantation as a quality system document: new prospects for computerization.

The usage of a computerized system to organize data and ease the activity procedures of liver transplantation is useful in clinical transplantation. Preliminary cognitive research on systems of clinical transplantation database concerning medical reports was performed to verify their development level. The survey highlighted that, so far, there has been no experimentation that can be applied to a medical report type devoted to liver transplantation. Regulations in force substantially point out that the medical report ought to contain all items that have to be taken into account in handling the patient from pretransplantation to follow-up. The Department of Transplantation of Genoa chose its medical report model for liver transplantation. The medical report model included the following items: personal data; case history; diagnosis; initial examination for prelisting; fitness for transplantation; assistance context; clinical data including subjective, objective, and instrumental parameters; pharmacological therapies; informed consent, evaluation of fitness; nursing data; counseling and clinical evaluations according to protocols and guidelines of the national transplantation centers. If the computing is well trained, it is supposed to help maintain a whole data view provided it is supplied information in an adequate way. Immediate clinical procedural advantages and useful scientific observations may be obtained from a high-quality database. In fact, all functions have to be applied to specific clinical, administrative needs to be remotely shared and conveniently integrated with each other to make the liver transplantation medical report an easy and handy instrument for inputting and handling data. It must be a precise, complete instrument that may be accessible in real time from any site connected with the intranet network, be unchangeable, and be protected to ensure certification and forensic medicine value.

Modifications of cerebral vascular resistance and autoregulation after graft reperfusion during human orthotopic liver transplantation.

We have studied cerebral blood flow velocity (CBFV) and cerebral autoregulation (CA) in 23 orthotopic liver transplantation (OLT) patients using transcranial doppler. CBFV was continuously recorded using a fixed (helmet) 2-Mz probe through the trans-temporal window. CA changes were studied using a linear regression analysis of percentile changes in CBFV and mean arterial blood pressure (MABP) after phenylephrine infusion compared with baseline. Pearson's "r" coefficient was considered an index of CA. In case of autoregulation is lost "r" tends to 1, thus representing complete dependence of CBFV on MABP. We regarded the slope coefficient parameter "S" as an index of cerebral vascular resistance (CVR), namely, the ratio of the corresponding variations of CBFV to MABP. Wilcoxon test showed a significant increase in both "r" and "S" between the anhepatic versus postreperfusion phases (within the first hour) and versus recovery in the neohepatic phase (end of surgery). A decreased CVR was observed within the first hour after graft reperfusion producing a loss of CA. These phenomena lead to an increase of CBFV and exposed the brain to hyperperfusion.

Benzodiazepine-like compounds in the plasma of patients with fulminant hepatic failure.

BACKGROUND: Benzodiazepine-like compounds have been implicated in the pathogenesis of encephalopathy after fulminant hepatic failure. METHODS: The levels and the nature of benzodiazepine-like compounds were determined in six cases of fulminant hepatic failure during the course of the disease. Blood samples were collected on admission and a few days later, when the neurologic status had improved in five cases and immediately before death in one case. The compounds were measured in sera with a binding technique after high-performance liquid chromatography purification and analyzed with mass spectrometry. RESULTS: Their levels were highly variable in those with severe encephalopathy and were still increased on awakening in some cases. Diazepam and N-desmethyldiazepam were inconsistently present. CONCLUSIONS: The inconsistent presence of benzodiazepine-like compounds in encephalopathy after fulminant hepatic failure and their persistence, in some cases, at high levels on awakening from coma seem to indicate that the encephalopathy is not strictly dependent on the levels of these compounds.

Changes in endogenous benzodiazepine-like compound levels during the course of fulminant hepatic failure: potential effects of decreased renal function.

The pathogenetic agents which cause encephalopathy due to fulminant hepatic failure are still under debate. Ammonia and benzodiazepine-like compounds are two of the most important agents considered, so far. Herein, we report the levels of benzodiazepine-like compounds in serum and in urine and of venous ammonia measured during the course of the disease (30 days). The patient rapidly developed stage IV encephalopathy with high levels of ammonia and with only a slight increase of benzodiazepine-like compounds. At that moment, the levels of these compounds were similar to those recorded in the blood when the patient regained full consciousness 28 days later. During the course of the disease, there was a 10-fold increase of benzodiazepine-like compounds in serum which was recorded in parallel with an impaired excretion due to oliguria. This observation seems to indicate that encephalopathy may develop in the absence of significantly increased levels of these compounds and that their episodic increase during fulminant hepatic failure may be an epiphenomenon linked with several factors such as impaired renal function.

Hepatic encephalopathy in liver transplant recipients precipitated by benzodiazepines present in transfused blood.

The observation that there are episodes of encephalopathy in liver cirrhosis patients after orthotopic liver transplantation, despite a well functioning graft and despite the lack of cerebral complications, prompted us to investigate the potential role of circulating benzodiazepine-like compounds in these episodes. The plasma levels of benzodiazepines were examined in 14 liver cirrhotic patients before and after transplantation. The benzodiazepines in the fluids infused during surgery and in individual bags of blood administered after surgery to 4 of these patients were also assayed. Herein we report that benzodiazepines accumulating in the blood of some transplanted patients appear to derive from blood transfusions utilized during surgery. The analysis of the types of benzodiazepines present in the blood utilized for transfusions suggests the use of commercial benzodiazepines by the donors. These compounds seem to be able to precipitate hepatic encephalopathy in patients with preexisting encephalopathy. Hence we suggest not using benzodiazepine consumers as blood donors, at least for patients with encephalopathy undergoing to liver transplantation.