Anesthesia Aspects of Multivisceral Transplantation: A Case Series Study.

Background: Multi-visceral transplantation (MvTx) usually refers to the transplantation of more than three intra-abdominal organs. A successful MvTx requires strong multidisciplinary teamwork of transplant surgeons, anesthesiologists, and intensivists. Case presentation: We present five cases of MvTx with a history of short bowel syndrome admitted to the Abu-Ali Sina Hospital, Shiraz, Iran from May 2019 to January 2020 and describe anesthetic considerations in MvTx. Subjects were identified (4F/1M) with a mean age of 43 years old (range 35-51). The most frequent cause of intestinal failure was portal vein thrombosis, followed by bowel gangrene and short bowel syndrome. The mean ±SD duration of the operation was 360±60 min. The bleeding volume was approximately 2600±1474 cc, and 4±1 bags of packed red blood cells were transfused. Sepsis was the main cause of death in our series. Conclusion: Careful preoperative planning, vigilant intraoperative anesthetic management, and prevention of postoperative infection are imperative to achieve the best outcomes.

The Effect of Perioperative N-acetylcysteine on the Short and Long Term Outcomes in Pediatrics Undergoing Living-Donor Liver Transplantation.

BACKGROUND: Ischemia-reperfusion injury during transplantation can cause post-operative graft dysfunction. OBJECTIVE: To assess the efficacy of N-acetylcysteine in preventing hepatic ischemia-reperfusion injury and post-transplant outcomes. METHODS: In this retrospective study on pediatrics undergoing living-donor (from one of their parents) liver transplantation, N-acetylcysteine was administered to one group (n=20) after induction in the donors until graft harvest, and in the recipients during implantation, which was maintained for 19 hours. The second group (n=20) did not receive NAC. Early allograft dysfunction was determined in the presence of alanine aminotransferase or aspartate aminotransferase ≥2000 IU/L and bilirubin ≥10 mg/dL within the first 7 days, and an international normalized ratio ≥1.6 on day 7. Data were collected from a retrospectively maintained database. RESULTS: The incidence of post-reperfusion syndrome was lower in N-acetylcysteine group compared with the other group (5% vs. 30%, p=0.037). Serum creatinine level was significantly (p=0.04) different in the N-acetylcysteine group during the second post-operative week (0.14 vs. 0.15 mg/dL). There was no significant difference in the incidence of early allograft dysfunction (21% vs. 14%, p=0.327), and the survival rate (p=0.409). CONCLUSION: Peri-operative infusion of N-acetylcysteine in both donor and recipient would effectively prevent post-reperfusion syndrome and renal insufficiency. However, it might not affect the early allograft dysfunction, ICU stay, and mortality. NAC increases the chance of re-operation due to non-surgical bleeding in the first post-operative day.

Restricted Crystalloid Fluid Therapy during Orthotopic Liver Transplant Surgery and its Effect on Respiratory and Renal Insufficiency in the Early Post-operative Period: A Randomized Clinical Trial.

BACKGROUND: Respiratory and renal insufficiencies are common dysfunctions during post-liver transplantation period that increase post-operative mortality and morbidity rates. Intra-operative fluid therapy is an important factor associated with pulmonary and renal insufficiency. OBJECTIVE: To evaluate the relation between intra-operative fluid therapy and early renal and respiratory insufficiency after liver transplantation. METHODS: In this randomized clinical study, 67 adult patients with end-stage liver disease who underwent orthotopic deceased donor liver transplantation were randomly allocated into two groups. The restricted fluid group, which received a controlled fluid administration of normal saline, 5 mL/kg/hr during anesthesia, and non-restricted fluid group received a controlled infusion of normal saline 10 mL/kg/hr during anesthesia. Early post-operative respiratory and renal insufficiency in both groups were assessed. The patients were monitored during the three stages of liver transplantation for their hemodynamic indices. The trial is registered with the Iranian Randomized Clinical Trial Registry, number IRCT2013101811662N4. RESULTS: The baseline demographic and clinical characteristics were similar in both studied groups. The prevalence of respiratory insufficiency in the non-restricted fluid group (15%) significantly (p=0.01) higher than that in the restricted fluid group (0%). The post-operative mean±SD serum creatinine was 1.0±0.1 mg/dL in the non-restricted fluid group and 1.1±0.2 in the restricted fluid group (p=0.43). No patients in the studied groups required post-operative continuous renal replacement therapy. CONCLUSIONS: Restricted crystalloid fluid administration during orthotropic liver transplantation though decreased post-operative chance of pulmonary insufficiency, did not increase renal dysfunction.

Gabapentin versus naproxen in the management of failed back surgery syndrome; a randomized controlled trial.

Gabapentin is an analogue of the gamma amino butyric acid (GABA), which regulates the conductance of calcium channels. In this study, we compared the efficacy of gabapentin the one of naproxen in the treatment of failed laminectomy syndrome. In this controlled trial, patients who had had elective lumbar discectomy or spinal fusion surgery more than one year ago, and complaining about leg and back pain in spite of different medical therapy were randomly assigned to receive naproxen (control group) or gabapentin. Gabapentin was started at a daily dose of 300 mg. This dose was increased by 300 mg at the end of each week up to a maximum dose of 1800 mg. Naproxen, which was administered at an initial daily dose of 250 mg, was increased similarly to the maximum 1500 mg. Patients were then followed up for the next 6 consecutive months. Back and leg pains were compared between the two groups at 9 consecutive time points, namely 0, 2, 4, 6, 8, 12, 16, 20 and 32 weeks after starting the treatment. The Visual Analog Scale (VAS) score of the back pain was significantly reduced when a 600 mg daily dose of gabapentin was reached (P < 0.001). At a dose of 1800 mg, the decrease in back pain amounted 20.5%. Naproxen-treated patients did not show significant improvement in back pain. Leg pain as similarly assessed by a VAS significantly decreased when a 1200 mg dose of gabapentin was attained (P < 0.008). At 1800 mg, the reduction in VAS was 39.2%. Naproxen-treated patients had a 7.7% pain reduction at 6th week, when using the maximum daily dose of 1500 mg (P < 0.04), but the pain increased thereafter. We conclude that Gabapentin, at a maximum daily dose of 1800 mg, is significantly more efficient than naproxen at treating persistent pain after spinal surgeries.

Combination of remifentanil with isoflurane or propofol: effect on the surgical stress response.

BACKGROUND: Hormonal and metabolic changes following surgery are markers of the stress response to surgery. We compared hemodynamic parameters and stress response markers (glucose, cortisol, and C-reactive protein) in two groups of patients receiving either propofol or isoflurane combined with remifentanil for maintenance of anesthesia. METHODS: We randomly assigned 100 women (ASA I-II) scheduled for diagnostic gynecologic laparoscopy to receive either isoflurane (0.8% end-tidal) or propofol (100 mg/kg/min) in addition to remifentanil (0.25 mg/ kg/min). Heart rate and mean arterial pressure were recorded after induction, 30 seconds after intubation, at four time points after incision, and 60 min after surgery. Serum C-reactive protein, cortisol and glucose concentrations were measured before induction, one hour after incision, and one hour after surgery. RESULTS: After induction, heart rate decreased significantly from baseline in both groups, and remained below baseline until the end of surgery. Mean arterial pressure also decreased significantly in both groups. C-reactive protein levels were not significantly different between groups. In the propofol group, cortisol decreased significantly one hour after incision, but increased in the isoflurane group. Glucose increased significantly in both groups, but was significantly lower in the propofol group one hour after the incision and one hour after surgery. CONCLUSION: An anesthetic regimen combining propofol and remifentanil attenuates two indicators of the stress response more efficiently than a isoflurane - remifentanil combination.

Very High Dose Epinephrine for the Treatment of Vasoplegic Syndrome during Liver Transplantation.

A 55-year-old man with hepatitis B and hepatocellular carcinoma was treated with liver transplantation without veno-venous bypass. During the procedure his arterial blood pressure remained at 55/30 mm Hg and did not respond to increasing doses of norepinephrine. Vasoplegia was managed aggressively with the intravenous infusion of high doses of epinephrine.

Serum Neutrophil Gelatinase-Associated Lipocalin versus Serum Creatinine for the Prediction of Acute Kidney Injury after Liver Transplantation.

BACKGROUND: Acute kidney injury (AKI) is a common complication after liver transplantation (LT), and considerably increases the morbidity and mortality of the procedure. The gold standard of measuring the kidney function, the serum creatinine level (sCr), has poor specificity and sensitivity for the early diagnosis of AKI. Novel biomarkers for the prediction or early diagnosis of AKI, would potentially increase the opportunities for therapeutic interventions. OBJECTIVE: To compare the diagnostic value of the standard renal marker, sCr and neutrophil gelatinase-associated lipocalin (NGAL) to predict AKI within 48 hours of LT. METHODS: During a 9-month period from 2010 to 2011, NGAL was measured two times in 90 patients who underwent LT from deceased donors-after induction of anesthesia (NGAL1) and 2 hours after reperfusion of the liver graft (NGAL2). Patients were grouped according to the presence of risk factors for developing AKI according to the Acute Kidney Injury Network criteria (increase of ≥0.3 mg/dL in plasma creatinine above the baseline value within 48 hours). RESULTS: 60 men and 30 women with mean±SD age of 40.2±14.2 years were included in this study. The incidence of AKI was 34% (95% CI: 24%-44%). The difference between the NGAL1 and NGAL2 (ΔNGAL) and the baseline NGAL concentration was predictive of AKI in all patients. Receiver operating characteristic (ROC) curve and area under curves (AUCs) of ΔNGAL and sCr levels during the first 48 hours of LT were similar in predicting AKI. The AUCs of the ΔNGAL to predict AKI was 0.64 (95% CI: 0.52-0.76). The development of AKI was significantly correlated with the number of units of fresh frozen plasma transfused intra-operatively (p=0.017) and cold ischemic time (p=0.042). CONCLUSION: Serum NGAL concentrations obtained during surgery is a predictor of AKI in patients undergoing LT.

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.

The effects of aqueous extract of vaccinium arctostaphylos leaves on blood pressure in renal hypertensive rats.

BACKGROUND: The leaves of Vaccinium arctostaphylos (Qare qat) is advocated for the treatment of hypertension in Iran' folk medicine. The objective of was to examine the possible hypotensive activity of aqueous extract of Vaccinium arctostaphylos leaves in rat model of two-kidney, one-clip hypertension. METHODS: Rats were subjected to sham operation of the placement of Plexiglass clip on left renal arteries. Four weeks later, renal artery clipped rats were given intravenous injection of normal saline or the extract at 10, 25, or 75 mg/kg, and mean blood pressure and heart rate were measured before and 20, 40 and 60 minutes after vehicle or drug administration. RESULTS: Compared to sham group, renal artery clipped groups had a significantly higher mean blood pressure, heart and right kidney weights, lower left kidney weight and significantly indifferent heart rate. Compared to vehicle treatment, the extract at 75 mg/kg, but not at 10 or 25 mg/kg, did reduce the mean blood pressure at 20, 40 and 60 minutes after administration without changing the heart rate. CONCLUSION: The findings showed that at a higher dose the extract did have hypotensive activity without changing the heart rate. The exact hypotensive mechanism remains to be investigated.

Hypotension after reperfusion in liver transplantation: histidine-tryptophan-ketoglutarate versus University of Wisconsin solution.

BACKGROUND: The greatest hemodynamic instability during orthotopic liver transplantation occurs at graft reperfusion. Many factors have been implicated. PURPOSE: To compare hemodynamic changes after reperfusion in grafted livers preserved with histidine-tryptophan-ketoglutarate (HTK) solution versus grafted livers preserved with University of Wisconsin (UW) solution. METHODS: In this prospective study, we randomly divided 89 patients who underwent deceased donor liver transplantation into 2 groups: the UW group and the HTK group. The HTK group was further divided into 2 subgroups: flushed and not flushed before reperfusion. The patients were monitored with hemodynamic and metabolic parameters at 3 times: after the skin incision, 5 minutes before reperfusion, and 5 minutes after reperfusion. RESULTS: Hemodynamic parameters in the UW group had not changed significantly at 5 minutes before reperfusion or 5 minutes after reperfusion (P = .45), and the incidence of hypotension after reperfusion in the UW group was 20%. In both HTK groups, the mean arterial pressure 5 minutes after reperfusion was significantly lower than at 5 minutes before reperfusion (P = .002); the incidence of hypotension after reperfusion in the nonflushed HTK group was 83.3% and in the flushed HTK group, 65.5%. CONCLUSIONS: The incidence of hypotension after reperfusion is greater if HTK solution rather than UW solution is used. Flushing of grafted livers preserved with HTK solution might eliminate some vasoactive substances found in HTK solution.

Post-reperfusion Syndrome and Outcome Variables after Orthotopic Liver Transplantation.

BACKGROUND: Post-reperfusion syndrome (PRS) is an important complication during liver transplantation. OBJECTIVE: 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. METHODS: 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. RESULTS: 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, retransplantation, dialysis, rejection and extended donor criteria did not differ significantly between groups. CONCLUSIONS: 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.

Liver transplantation for homozygous familial hypercholesterolemia: two case reports.

Homozygous familial hypercholesterolemia (HFHC) is a rare inherited condition with an incidence of one in one million. It is associated with severe premature atherosclerosis and early death from cardiovascular complications. Mutation in the gene that encodes the synthesis of the cellular receptor for low-density lipoprotein (LDL) is responsible for this metabolic disorder. Currently, the only effective treatment for this disease is liver transplantation, which alone or in association with medications, normalizes plasma cholesterol level. The authors report the results of liver transplantation for two cases of HFHC. The first case, a 15-year-old boy received a whole liver from a deceased donor, and the second, an 11-year-old boy, received a left liver lobe transplant from his mother's sister. Their preoperative fasting lipid concentrations were grossly raised. The older boy had severe atherosclerotic heart disease and had undergone coronary artery bypass grafting 5 months before transplantation. Both had preoperative plasma cholesterol levels higher than 750 mg/dL with normal thyroid and liver function tests. After the operation, the patients received methylprednisolone as pulse therapy followed by oral prednisolone, mycophenolate mofetil, and tacrolimus for immunosuppression. Their hospital stays were 24 and 13 days, respectively. The first case needed reexploration because of bleeding on the second day after the operation. The lipid concentrations rapidly returned to the normal range in the first week after the operation, remaining in this range over the first 6 months of follow-up. Liver transplantation offers an highly effective treatment for HFHC. It is better to operate on patients before severe atherosclerotic changes in the coronary arteries. All patients must undergo a complete cardiac evaluation before surgery.

Early hepatic artery thrombosis after liver transplantation: diagnosis and treatment.

BACKGROUND: Hepatic artery thrombosis (HAT) occurs in 3% to 9% of all liver transplantations with acute graft failure as a possible sequel. METHODS: Eleven episodes of HAT were identified among 256 orthotropic liver transplantations (whole, LDCT, split) performed on 253 patients between April 1993 and July 2006. HAT was suspected clinically and confirmed by Doppler ultrasonography, magnetic resonance angiography, angiography, or reexploration. One patient was excluded due to poor follow-up. Treatment options included exploration with HA thrombectomy plus thrombolysis, retransplantation, or conservative treatment of hepatic and biliary complications. RESULTS: Among 11 patients of mean age 29.98 +/- 17.14 years (range, 10 months to 56 years). 2 had split right lobe liver transplantations and 9 received whole organs. None of LDLTs were identified to have HAT. The causes of liver cirrhosis among HAT patients were autoimmune hepatitis (n=3), cryptogenic (n=3), Wilson (n=1), PBC (n=1), biliary atresia (n=1), and HBs (n=1). HAT was diagnosed at 5.9 +/- 4.43 (range, 2 to 16) days after operation. Most patients developed right upper quadrant (RUQ) pain at presentation. Two patients developed acidosis, fever, or SIRS and underwent retransplantation. Four underwent exploration of HA and 1 was treated conservatively. Three cases expired due to HAT complications. CONCLUSION: We found RUQ pain to be the presenting sign of early HAT in majority of cases. RUQ pain has been reported to occur in late HAT. Whenever HAT is confirmed, liver transplanted patients should be revascularized or even retransplanted. Intra-arterial thrombolysis and thrombolytic therapy for HAT should be done cautiously due to the potential risk of hemorrhage.

The effect of clamping of inferior vena cava and portal vein on urine output during liver transplantation.

BACKGROUND: Intraoperative hypotension, massive transfusion, liver disease, coexistent renal dysfunction, and decreased glomerular filtration rate during the anhepatic phase are major hazards for kidney function. We undertook this study to determine the change in urine output during clamping. METHOD: Twenty-four patients without preexistent renal disease, who were undergoing liver transplantation using the piggyback method, were enrolled in this study. Patients with a serum creatinine level >1.2 mg/dL were excluded. Urine output was monitored over 30 minutes before inferior vena cava and portal vein clamping, during clamping, and for 30 minutes after declamping. None of the patients had a clamping time >70 minutes. Our goal was to maintain mean arterial blood pressure and heart rate just by fluid administration diuretics were avoided. RESULTS: Participants had a mean age of 39.12 +/- 13.52 years (range, 15-67 years) with a male to female ratio of 1:4. Urine output 30 minutes before clamping was 3.64 +/- 3.58 (range, 1.25-15.18) mL/kg/h, decreased to 1.28 +/- 2.58 (range, 0-11.39) mL/kg/h during clamping (P=.00), and increased to 3.56 +/- 3.64 (range, 0.51-15.18) mL/kg/h 30 minutes after declamping (P=.00). CONCLUSION: Urine output was significantly reduced in all patients after clamping of the IVC and portal veins. This observation may be explained by increased venous pressure leading to decreased renal perfusion pressure. It has been stated that one of the advantages of veno-veno bypass (VVB) is increased renal perfusion pressure. However, if the clamping time in the piggyback method is <70 minutes and patients have normal preoperative renal function, the decreased renal perfusion pressure will not cause postoperative kidney dysfunction.

Results of liver transplantation: analysis of 140 cases at a single center.

The Shiraz Organ Transplant Center in southern Iran has been performing all liver transplantations in Iran and certain neighboring countries for 12 years. This study evaluated the 140 operations performed from April 1993 through November 2004. Sixty-one percent of the recipients were men and 39% were women. The average recipient age was 29.9 +/- 14.0 years. One hundred twenty-eight patients has a full-size cadaveric transplant. Most frequent causes of cirrhosis were cryptogenic and viral. An acute rejection episode occurred in 47.5% of cases, and two episodes in 8%. Most frequent short-term complications included respiratory, neurologic, and biliary problems. The 1-, 2-, and 3-year patient survival rates were 92%, 89%, and 85%, respectively. The experience that the Shiraz Organ Transplant Center has had with liver transplantation indicated success comparable to that noted in other reports. The calculated trend suggests that a goal of 100 transplantations for 2005 is within reach.

An assessment of the value of rectus sheath block for postlaparoscopic pain in gynecologic surgery.

STUDY OBJECTIVE: To compare the effect of the bilateral rectus sheath block (BRSB) by bupivacaine in decreasing postlaparoscopic pain with the intraperitoneal (IP) and intraincisional (II) use of this drug. DESIGN: Randomized, double-blind, clinical trial (Canadian Task Force Classification I). SETTING: University teaching hospital. PATIENTS: Ninety-one women with unexplained infertility. MEASUREMENTS AND MAIN RESULTS: Patients were randomly allocated to one of three groups. In group I, BRSB was performed with 25 mg of bupivacaine. For groups II and III, IP and II instillation, respectively, of 25 mg of bupivacaine was performed. Postoperative pain was assessed by visual analog pain score (VAS) 1, 6, 10, and 24 hours postoperatively. The VAS was significantly lower in group I at 6 hours (p <.001) and 10 hours (p <.004) after laparoscopy. CONCLUSION: Bilateral rectus sheath block can effectively decrease postlaparoscopic pain at 6 and 10 hours after the operation when compared with IP and II use of bupivacaine.

The effect of ketamine and fentanyl in reducing the pain of diazepam injection.

Diazepam is an effective drug that is used widely in modern anesthesia. Venous irritation is one of its major side effects attributed to its acqueous insolubility and requisite solvents. There is some evidence that ketamine may acts as a local anesthetic drug, because of its effect on N-methyl-D-aspartate receptors. Fentanyl also may reduce the pain of diazepam injection by blocking the opiate receptors in vessels walls. To determine the effectiveness of ketamine and fentanyl in reducing the pain of diazepam injection, 150 patients (ASA I, II) were randomly assigned to one of three Groups and before intravenous diazepam injection. 2 ml normal saline, 2 ml fentanyl or 10 mg ketamine were administered for Groups 1, 2, 3 respectively. The pain of diazepam injection was then evaluated at 30 minutes intervals. Our results showed that ketamine and fentanyl reduce the pain of diazepam dramaticaly (p < 0.001) in comparison with placebo. Ketamine is more effective than fentanyl in reducing such pain (p < 0.001).