ABSTRACT
PURPOSE OF REVIEW: The purpose of this review is to summarize the most recent up to date research data and recommendations regarding anaesthetic management of patients with liver disease undergoing surgery. The incidence of chronic liver disease (CLD) continues to rise and perioperative mortality and morbidity remains unacceptably high in this group. Meticulous preoperative assessment and carefully planned anaesthetic management are vital in improving outcomes in patients with liver disease undergoing surgery. RECENT FINDINGS: The presence of cirrhosis is associated with a significantly increased risk of postoperative morbidity and mortality in patients undergoing elective surgery. The Child--Pugh--Turcotte scale and model for end-stage liver disease (MELD) score remain the most commonly applied scoring systems in preoperative risk assessment, but new MELD-based indices and novel scoring systems might offer better prognostic value. Propofol and new inhalational agents (sevoflurane, desflurane) are recommended hypnotic agents. The titration of opiates in the perioperative period is recommended because of their altered metabolism in patients with liver disease. Perioperative management should include close haemodynamic monitoring and admission to a critical care area should be considered. SUMMARY: Patients with liver disease undergoing anaesthesia pose significant challenges and advanced planning and preparation are required in order to improve perioperative outcomes in this group. VIDEO ABSTRACT: http://links.lww.com/COAN/A43.
Subject(s)
Anesthesia/adverse effects , Elective Surgical Procedures/adverse effects , End Stage Liver Disease/surgery , Hypnotics and Sedatives/adverse effects , Perioperative Care/methods , Anesthesia/methods , Desflurane , End Stage Liver Disease/complications , End Stage Liver Disease/epidemiology , End Stage Liver Disease/metabolism , Humans , Hypnotics and Sedatives/administration & dosage , Incidence , Isoflurane/administration & dosage , Isoflurane/adverse effects , Isoflurane/analogs & derivatives , Methyl Ethers/administration & dosage , Methyl Ethers/adverse effects , Monitoring, Physiologic , Opiate Alkaloids/administration & dosage , Opiate Alkaloids/adverse effects , Opiate Alkaloids/metabolism , Postoperative Complications/epidemiology , Postoperative Complications/etiology , Prognosis , Propofol/administration & dosage , Risk Assessment , Severity of Illness Index , Sevoflurane , Treatment OutcomeABSTRACT
Familial dysautonomia (Riley-Day syndrome) is a rare multisystem disorder associated with an excess risk of perioperative morbidity and mortality. Because life expectancy is limited, few reports consider the perioperative management of familial dysautonomia in adults with advanced disease and end-organ dysfunction. Here, we report on the management of an adult patient with familial dysautonomia, highlighting recent developments in perioperative technology and pharmacology of special relevance to this challenging population.
Subject(s)
Dysautonomia, Familial/surgery , Adult , Blood Pressure/physiology , Cardiac Output/physiology , Dysautonomia, Familial/physiopathology , Humans , Male , Monitoring, Intraoperative/methods , Perioperative Care/methods , Postoperative Care/methodsABSTRACT
BACKGROUND: Recent studies have shown that fish oil, containing omega-3 polyunsaturated fatty acids (omega-3 PUFAs) eicosapentaenoic acid (EPA) (C20:5 omega 3), and docosahexaenoic acid (DHA) (C22:6 omega 3) retard the progression of renal disease, especially in IgA nephropathy (IgAN). Despite increasing knowledge of the beneficial effects of fish oils, little is known about the mechanisms of action of omega-3 PUFAs. It has been reported that activation of peroxisome proliferator-activated receptors (PPARs) inhibits production of proinflammatory cytokines. Both EPA and DHA have been shown to activate PPARs. The aim of this study was to examine if omega-3 PUFAs have anti-inflammatory effects via activation of PPARs in human renal tubular cells. METHODS: An immortalized human proximal tubular cell line [human kidney-2 (HK-2) cells] was used in all experiments. Conditioned media was collected from omega-3 PUFAs- treated cells and subjected to enzyme-linked immunosorbent assay (ELISA). Total cellular RNA was isolated from the above cells for real-time quantitative polymerase chain reaction (PCR). Nuclear Extracts were prepared from the HK-2 cells for transcription factor activation assay. RESULTS: Both EPA and DHA at 10 micromol/L and 100 micromol/L concentrations effectively decreased lipopolysaccharide (LPS)-induced nuclear factor-kappaB (NF-kappaB) activation and monocyte chemoattractant protein-1 (MCP-1) expression. EPA and DHA also increased both PPAR-gamma mRNA and protein activity (two- to threefold) in HK-2 cells. A dose of 100 micromol/L bisphenol A diglycidyl ether (BADGE) abolished the PPAR-gamma activation induced by both EPA and DHA and removed the inhibitory effect of EPA and DHA on LPS-induced NF-kappaB activation in HK-2 cells. Overexpression of PPAR-gamma further inhibited NF-kappaB activation compared to the control cells in the presence of EPA and DHA. CONCLUSION: Our data demonstrate that both EPA and DHA down-regulate LPS-induced activation of NF-kappaB via a PPAR-gamma-dependent pathway in HK-2 cells. These results suggest that PPAR-gamma activation by EPA and DHA may be one of the underlying mechanisms for the beneficial effects of fish oil.
