Lack of alloimmunization to the D antigen in D-negative orthotopic liver transplant recipients receiving D-positive red blood cells perioperatively.

BACKGROUND AND OBJECTIVES: D-negative patients undergoing orthotopic liver transplantation (OLT) might require a large number of red blood cell (RBC) units, which can impact the inventory of D-negative blood. The blood bank might need to supply these patients with D-positive RBCs because of inventory constraints. This study evaluates the prevalence of anti-D formation in D-negative OLT patients who received D-positive RBCs perioperatively, as this will assist in successful patient blood management. MATERIALS AND METHODS: This was a retrospective study performed at a single academic medical centre. Electronic medical records for all 1052 consecutive patients who underwent OLT from January 2007 through December 2017 were reviewed. D-negative patients who were transfused perioperatively with D-positive RBCs and had antibody screening at least 30 days after transfusion were included. RESULTS: Of a total of 155 D-negative patients, 23 (14.8%) received D-positive RBCs perioperatively. Seventeen patients were included in the study. The median age was 54 years (range 36-67 years); 13 (76.5%) were male. The median number of D-positive RBC units transfused perioperatively was 7 (range 1-66 units). There was no evidence of D alloimmunization in any patient after a median serologic follow-up of 49.5 months (range 31 days to 127.7 months). The average number of antibody screening post OLT was 7.29. CONCLUSION: Our study showed that transfusion of D-positive RBCs in D-negative OLT recipients is a safe and acceptable practice in the setting of immunosuppression. This practice allows the conservation of D-negative RBC inventory.

Transfusion requirements and alloimmunization to red blood cell antigens in orthotopic liver transplantation.

BACKGROUND AND OBJECTIVES: Orthotopic liver transplantation (OLT) has been associated with high blood transfusion requirements. We evaluated the transfusion needs and frequency of alloimmunization to RBC antigens among OLT recipients pre- and post-transplantation. MATERIALS AND METHODS: We reviewed the medical records of patients who underwent a first OLT between January 2007 and June 2017. Transfusions given only during the perioperative period, defined by 1 week before OLT until 2 weeks following OLT, were included in this study. Records were reviewed in June 2019 for updated antibody testing results. RESULTS: A total of 970 patients underwent OLT during the study period. The median age of patients was 57 years; 608(62.7%) were male. During the perioperative period, transfused patients received an average of 10.7 (±10.7) RBC units, 15.6 (±16.2) thawed plasma units and 4.1 (±4.3) platelet units. At the time of OLT, a total of 101 clinically significant RBC alloantibodies were documented in 58(5.98%) patients. Fifty-three of these antibodies were directed against Rh blood group antigens. Twenty-two (37.9%) patients had more than one alloantibody. Patients with alloimmunization before OLT (N = 58) received perioperatively comparable number of RBCs to non-alloimmunized patients (10.5 ± 10.6 vs. 9.6 ± 10.7; p = 0.52). There was no significant difference in perioperative or intraoperative RBC transfusion between patients with one alloantibody and those with multiple alloantibodies. Only 16 patients (16/737; 2.17%) developed new alloantibodies at a median of 61 days after OLT. The overall alloimmunization rate was 9.8% (72/737), and female patients were more likely to be alloimmunized. CONCLUSION: Blood transfusion requirements in OLT remain high. However, the rate of RBC alloimmunization was not higher than the general patient population.

TEE image quality improvement with our devised probe cover.

OBJECTIVE(S): Our hypothesis was that our devised transesophageal echocardiography probe cover with the capacity for pinpoint suction would improve image quality. DESIGN: Prospective cohort study. SETTING: Single tertiary medical center. PARTICIPANTS: Patients undergoing surgery requiring intraoperative transesophageal echocardiography. INTERVENTIONS: Suctioning with inserted orogastric tube. MEASUREMENTS AND MAIN RESULTS: Changes in image quality with suctioning were assessed by 2 methods. In method #1, investigators categorized the quality of all acquired images on a numeric scale based on each investigator's impression (1: very poor, 2: poor, 3: acceptable, 4: good, and 5: very good). In method #2, the reproducibility of the left ventricular fraction area change (LV FAC) was assessed, assuming that improved transgastric midpapillary short-axis view image quality would yield better LV FAC reproducibility. With method #1, for midesophageal views, 26.5%, 70.5%, and 3.0% of images showed improved, the same, and worsened image quality, respectively. For transgastric views, 55.3%, 43.3%, and 1.4% showed improved, the same, and worsened image quality, respectively. For deep transgastric views, 60.0%, 38.0%, and 2.0% showed improved, the same, and worsened image quality, respectively. With method #2, the presuction group had an ICC of 0.942 (95% CI: 0.91, 0.965). The postsuction group had an ICC of 0.988 (95% CI: 0.981, 0.993). CONCLUSIONS: Our investigation validates the potential image quality improvement withour devised TEE probe cover. However, its clinical validity needs to be confirmed by further studies.

Immediate Postoperative Extubation Decreases Pulmonary Complications in Liver Transplant Patients.

BACKGROUND: Fast-track anesthesia in liver transplantation (LT) has been discussed over the past few decades; however, factors associated with immediate extubation after LT surgery are not well defined. This study aimed to identify predictive factors and examine impacts of immediate extubation on post-LT outcomes. METHODS: A total of 279 LT patients between January 2014 and May 2017 were included. Primary outcome was immediate extubation after LT. Other postoperative outcomes included reintubation, intensive care unit stay and cost, pulmonary complications within 90 days, and 90-day graft survival. Logistic regression was performed to identify factors that were predictive for immediate extubation. A matched control was used to study immediate extubation effect on the other postoperative outcomes. RESULTS: Of these 279 patients, 80 (28.7%) underwent immediate extubation. Patients with anhepatic time >75 minutes and with total intraoperative blood transfusion ≥12 units were less likely to be immediately extubated (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.26-0.89; P = 0.02; OR, 0.11; 95% CI, 0.05-0.21; P < 0.001). The multivariable analysis showed immediate extubation significantly decreased the risk of pulmonary complications (OR, 0.34; 95% CI, 0.15-0.77; P = 0.01). According to a matched case-control model (immediate group [n = 72], delayed group [n = 72]), the immediate group had a significantly lower rate of pulmonary complications (11.1% versus 27.8%; P = 0.012). Intensive care unit stay and cost were relatively lower in the immediate group (2 versus 3 d; P = 0.082; $5700 versus $7710; P = 0.11). Reintubation rates (2.8% versus 2.8%; P > 0.9) and 90-day graft survival rates (95.8% versus 98.6%; P = 0.31) were similar. CONCLUSIONS: Immediate extubation post-LT in appropriate patients is safe and may improve patient outcomes and resource allocation.