Predicting fluid responsiveness in patients undergoing orthotopic liver transplantation: effects on intraoperative blood transfusion and postoperative complications.

OBJECTIVE: To test the hypothesis that the restrictive volume therapy decreases blood transfusion requirement during liver orthotopic transplantation (OLT) without increasing acute renal complications and hospital length stay. MATERIAL AND METHODS: We conducted a retrospective cohort study (n = 89), randomized into 2 groups: A (liberal fluid strategy) and B (restrictive therapy). We analyzed packed red blood cells (PRBCs) units, transfused units of fresh frozen plasma (FFP), colloids, crystalloids, perioperative renal function, and hospital length stay. For comparison of proportions, we used the χ(2) test and Student t test to compare means (parametric). A logistic regression model was constructed to evaluate the association of all these variables with probability of PRBCs transfusion. RESULTS: In group A, 88.4% of patients required intraoperative transfusion of PRBCs, with a mean of 8.5 ± 7.02 IU, compared with 82.2% in group B with a mean of 5.02 ± 4.5 IU (P < .001). We also found differences in the following variables: FFP transfusion rate was 95.3% (mean, 15.02 ± 8.2 IU) in group A and 75.6% (mean, 8.7 ± 6.04 IU) in B (P < .001). The amount of colloid was 50% (mean, 692.8 ± 409.6 mL) in group A and 28.9% (mean, 607.6 ± 316.7 mL) in B (P = .032). Platelet concentrates transfusion was 79.1% (mean, 2.05 ± 1.1 IU) in group A and 51.1% (mean, 2.0 ± 1.08 IU) in B (P = .014). As an important effect of restrictive fluid therapy, renal function was assessed; no differences in mean creatinine or acute renal failure in the immediate postoperative period were observed. There was no difference in hospital length stay. Logistic regression modelling identified 3 variables as significant predictors of transfusion: Fluid administration policy, preoperative hemoglobin and FFP units transfused. Furthermore, an increase of preoperative hemoglobin is associated with a lesser probability of transfusion. CONCLUSIONS: These results show that fluid restriction management for OLT decreased blood products requirements, especially FFP. This could suggest that liberal fluid management may aggravate, rather than prevent, bleeding in these patients. We did observed any no difference in failure of renal function.

Probabilidad clínica de tromboembolismo pulmonar: beneficio diagnóstico de las escalas de predicción y de los dímeros D / Clinical suspicion of pulmonary embolism: diagnostic utility of prediction scores and D-dimer measurement

Objetivo: Determinar la precisión de las escalas de Wells, Ginebra y los dímeros-D en pacientes con sospecha clínica de tromboembolismo pulmonar (TEP). Método: Estudio de cohorte prospectivo de precisión diagnóstica de la sospecha de TEP (escalas de Wells y Ginebra y los dímeros D). Análisis de una base de datos de 637 pacientes consecutivos con sospecha de TEP ingresados en el servicio de urgencias generales de un hospital terciario. La medida de resultados muestra la sensibilidad, especificidad, valores predictivos positivo/negativo (VPP/VPN) y las razones de verosimilitud positivas y negativas (RV+/RV-). El patrón oro fue la confirmación de TEP mediante la tomografía computarizada y el seguimiento a 3 meses. Resultados: La edad media fue de 67,9 (DE: 16,3) años y el 54,6% fueron mujeres. La prevalencia global de TEP fue 15,1%. Para la escala de Wells el VPN fue 85,3% (IC 95%: 82,1-88,0), el VPP 62,5% (IC 95%: 42,7-78,8), la sensibilidad 15,6% (IC 95%: 9,7-24,2), la especificidad 98,1% (IC 95%: 96,5-99,0), la RV+ 8,3 (IC 95%: 3,7-18,4) y la RV- 0,86 (IC 95%: 0,78-0,95). Para la de Ginebra, el VPN fue 82,8% (IC 95%: 78,9-86,0), el VPP 58,8% (IC 95%: 36,0-78,4), la sensibilidad 11,8% (IC 95%: 6,5-20,3), la especificidad 98,1% (IC 95%: 96,1-99,1), la RV+ 6,2 (IC 95%: 2,42-15,74) y la RV- 0,90 (IC 95%: 0,81-1,0). Para el dímero-D, el VPN fue 99,2% (IC 95%. 95,4-99,9), el VPP 21,7% (IC 95%: 18,1-25,9), la sensibilidad 98,9% (IC 95%: 94,2-99,8), especificidad 26,4% (IC 95%: 22,6-30,7), la RV+ 1,34 (IC 95%: 1,27-1,43) y la RV- 0,04 (IC 95%: 0,01-0,29). Conclusiones: De acuerdo con los resultados obtenidos la escala de Wells y Ginebra son buenas candidatas para ser utilizadas en urgencias como escalas para establecer la sospecha de TEP; y la de Wells sería la escala de elección por su superior especificidad. Sin embargo ninguna de ellas puede ser utilizada como herramienta diagnóstica por su baja sensibilidad. Así mismo, los dímeros D son una prueba que nos permite excluir el TEP, cuando el resultado es negativo, pero éstos debieran ser aplicados conjuntamente con las escalas

Objective: To assess the utility of the Wells and Geneva scoring systems and D-dimer measurements when pulmonary embolism (PE) is suspected. Methods: Prospective cohort study of the diagnostic performance of the Wells and Geneva scores and D-dimer measurement. We analyzed data for 637 consecutive patients suspected of having PE; the patients were being treated in the emergency department of a tertiary care hospital. The following performance measures were assessed: sensitivity, specificity, positive and negative predictive values (PPV and NPV), and the positive and negative likelihood ratios (LR+ and LR-). PE was confirmed by computed tomography and the patients were followed for the recommended 3 months. Results: The mean (SD) age was 67.9 (16.3) years and 54.6% of the patients were women. The prevalence of PE in the cohort was 15.1%. For the Wells score, the NPV was 85.3% (95% CI, 82.1%-88.0%), and the PPV was 62.5% (95% CI, 42.7%-78.8%). Sensitivity was 15.6% (95% CI, 9.7%-24.2%) and specificity 98.1% (95% CI, 96.5%-99.0%). The LR+ was 8.3 (95% CI, 3.7-18.4), and the LR- was 0.86 (95% CI, 0.78-0.95). For the Geneva score, the NPV was 82.8% (95% CI, 78.9%-86.0%), and the PPV was 58.8% (95% CI, 36.0%-78.4%). Sensitivity was 11.8% (95% CI, 6.5%-20.3%) and specificity 98.1% (95% CI, 96.1%-99.1%). The LR+ was 6.2 (95% CI, 2.42-15.74), and the LR- was 0.90 (95% CI, 0.81-1.0). For D-dimer level, the NPV was 99.2% (95% CI, 95.4%-99.9%), and the PPV was 21.7% (95% CI, 18.1%-25.9%). Sensitivity was 98.9% (95% CI, 94.2%-99.8%) and specificity 26.4% (95%, 22.6%-30.7%). The LR+ was 1.34 (95% CI, 1.27-1.43), and the LR- was 0.04 (95% CI, 0.01-0.29). Conclusions: The Wells and Geneva scoring systems are good useful in the emergency department for establishing a preliminary clinical diagnosis of suspected PE. The Wells score has better specificity. However, diagnosis cannot be based on any of these tools because of their low sensitivity. Similarly, D-dimer measurement can allow PE to be ruled out when the result is negative, but this criterion must be used in conjunction with the scoring systems

[Kikuchi-Fujimoto disease: review of four cases]. / Enfermedad de Kikuchi-Fujimoto: estudio de cuatro casos.

Kikuchi-Fujimoto disease is an uncommon form of lymphadenitis, firstly described in Japan. Etiology is unknown. It affects mainly young women. It commonly manifests as a painful cervical lymphadenitis usually associated with fever and leukopenia. Clinical course users to be benign, leading spontaneously to a complete recovery. Histological findings include necrotizing changes with cariorrhesis, partial loss of ganglionar architecture and foci of histiocytic infiltrates in the cortical and/or paracortical zones of the lymph nodes. A common finding is the absence of neutrophil granulocytes in the inflammatory infiltrates, in contrast to other necrotizing lymphadenitis. We report four cases of Kikuchi-Fujimoto disease, recently identified in our hospital.

Enfermedad de Kikuchi-Fujimoto: estudio de cuatro casos / Kikuchi-Fujimoto disease: review of four cases

La enfermedad de Kikuchi Fujimoto es una forma inusual de linfadenitis observada inicialmente en Japón. La etiología es desconocida y afecta preferentemente a mujeres jóvenes en forma de linfadenitis cervical dolorosa asociado con frecuencia fiebre y leucopenia. Se trata de una enfermedad benigna y de resolución espontánea. La lesión histológica se caracteriza por fenómenos necróticos con cariorrexis, pérdida parcial de la estructura ganglionar y focos de histiocitos en la zona cortical y/o paracortical. Un hallazgo característico es la ausencia de granulocitos neutrófilos, lo que la diferencia de otras linfadenitis necrotizantes. Recogemos cuatro casos de enfermedad de Kikuchi-Fujimoto atendidos en nuestro centro en un año. Tres pacientes eran adultos y el otro una niña en edad pediátrica. La mitad referían fiebre y los cuatro tuvieron adenopatías. La evolución fue buena en todos. Pensamos que la enfermedad de Kikuchi-Fujimoto es probablemente más frecuente en nuestro país que lo recogido en la literatura

Kikuchi Fujimoto disease is an uncommon form of lymphadenitis, firstly described in Japan. Etiology is unknown. It affects mainly young women. It commonly manifests as a painful cervical lymphadenitis usually associated with fever and leukopenia. Clinical course users to be benign, leading spontaneously to a complet recovery. Histological findings include necrotizing changes with cariorrhesis, partial loss of ganglionar architecture and foci of histiocytic infiltrates in the cortical and/or paracortical zones of the lymph nodes. A common findings is the absence of neutrophil granulocytes in the inflammatory infiltrates, in contrast to other necrotizing lymphadenitis. We report four cases of Kikuchi Fujimoto disease, recently identified in our hospital