Practical model to identify liver transplant recipients at low risk of postoperative haemorrhage, bile leakage and ascites.

BACKGROUND: This study aimed to identify a subgroup of recipients at low risk of haemorrhage, bile leakage and ascites following liver transplantation (LT). METHODS: Factors associated with significant postoperative ascites (more than 10 ml/kg on postoperative day 5), bile leakage and haemorrhage after LT were identified using three separate multivariable analyses in patients who had LT in 2010-2019. A model predicting the absence of all three outcomes was created and validated internally using bootstrap procedure. RESULTS: Overall, 944 recipients underwent LT. Rates of ascites, bile leakage and haemorrhage were 34.9, 7.7 and 6.0 per cent respectively. The 90-day mortality rate was 7.0 per cent. Partial liver graft (relative risk (RR) 1.31; P = 0.021), intraoperative ascites (more than 10 ml/kg suctioned after laparotomy) (RR 2.05; P = 0.001), malnutrition (RR 1.27; P = 0.006), portal vein thrombosis (RR 1.56; P = 0.024) and intraoperative blood loss greater than 1000 ml (RR 1.39; P = 0.003) were independently associated with postoperative ascites and/or bile leak and/or haemorrhage, and were introduced in the model. The model was well calibrated and predicted the absence of all three outcomes with an area under the curve of 0.76 (P = 0.001). Of the 944 patients, 218 (23.1 per cent) fulfilled the five criteria of the model, and 9.6 per cent experienced postoperative ascites (RR 0.22; P = 0.001), 1.8 per cent haemorrhage (RR 0.21; P = 0.033), 4.1 per cent bile leak (RR 0.54; P = 0.048), 40.4 per cent severe complications (RR 0.70; P = 0.001) and 1.4 per cent 90-day mortality (RR 0.13; P = 0.004). CONCLUSION: A practical model has been provided to identify patients at low risk of ascites, bile leakage and haemorrhage after LT; these patients could potentially qualify for inclusion in non-abdominal drainage protocols.

Management of liver failure in general intensive care unit.

OBJECTIVE: To produce French guidelines on Management of Liver failure in general Intensive Care Unit (ICU). DESIGN: A consensus committee of 23 experts from the French Society of Anesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Association for the Study of the Liver (Association française pour l'étude du foie, AFEF) was convened. A formal conflict-of-interest (COI) policy was developed at the start of the process and enforced throughout. The entire guideline process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were ungraded. METHODS: Two fields were defined: acute liver failure (ALF) and cirrhotic patients in general ICU. The panel focused on three questions with respect to ALF: (1) Which etiological examinations should be performed to reduce morbidity and mortality? (2) Which specific treatments should be initiated rapidly to reduce morbidity and mortality? (3) Which symptomatic treatment should be initiated rapidly to reduce morbidity and mortality? Seven questions concerning cirrhotic patients were addressed: (1) Which criteria should be used to guide ICU admission of cirrhotic patients in order to improve their prognosis? (2) Which specific management of kidney injury should be implemented to reduce morbidity and mortality in cirrhotic ICU patients? (3) Which specific measures to manage sepsis in order to reduce morbidity and mortality in cirrhotic ICU patients? (4) In which circumstances, human serum albumin should be administered to reduce morbidity and mortality in cirrhotic ICU patients? (5) How should digestive haemorrhage be treated in order to reduce morbidity and mortality in cirrhotic ICU patients? (6) How should haemostasis be managed in order to reduce morbidity and mortality in cirrhotic ICU patients? And (7) When should advice be obtained from an expert centre in order to reduce morbidity and mortality in cirrhotic ICU patients? Population, intervention, comparison and outcome (PICO) issues were reviewed and updated as required, and evidence profiles were generated. An analysis of the literature and recommendations was then performed in accordance with the GRADE® methodology. RESULTS: The SFAR/AFEF Guidelines panel produced 18 statements on liver failure in general ICU. After two rounds of debate and various amendments, a strong agreement was reached on 100% of the recommendations: six had a high level of evidence (Grade 1 ±), seven had a low level of evidence (Grade 2 ±) and six were expert judgments. Finally, no recommendation was provided with respect to one question. CONCLUSIONS: Substantial agreement exists among experts regarding numerous strong recommendations on the optimum care of patients with liver failure in general ICU.

Can we refine the management of blunt liver trauma?

AIM: To describe the management of blunt liver injury and to study the potential relation between delayed complications, type of trauma mechanisms and liver lesions. PATIENTS AND METHODS: This is a retrospective single center study including 116 consecutive patients admitted with blunt liver injury between 2007 and 2015. RESULTS: Initial CT-scan identified an active bleeding in 33 (28%) patients. AAST (American Association for the Surgery of Trauma) grade was 1 to 3 in 82 (71%) patients and equal to 5 in 15 (13%) patients. Eighty (69%) patients had NOM, with a success rate of 96%. Other abdominal organ lesions were associated to invasive initial management. A follow-up CT-scan was useful to detect hepatic and extra-hepatic complications (46 complications in 80 patients), even without clinical or biological abnormalities. Subsequent hepatic complications such as bleeding, pseudo aneurysms, biloma and biliary peritonitis developed in 15 patients and were associated with the severity of blunt liver injury according to AAST classification (3.7±1.0 vs. 3.0±1.1, P=0.010). Total biliary complications occurred in 13 patients and were significantly more frequently observed in patients with injury of central segments 1, 4 and 9 (69% vs. 36%, P=0.033). CONCLUSIONS: Non-operative management is possible in most blunt liver injury with a success rate of 96%. A systematic CT-scan should be advocated during follow-up, especially when AAST grade is equal or superior to 3. Biliary complications should be suspected when lesions involve segments 1, 4 and 9.

Cardiac troponin I as an early prognosis biomarker after trauma: a retrospective cohort study.

BACKGROUND: The significance of cardiac troponin I (cTnI) elevation after trauma is debated. We therefore explored the association between cTnI elevation at admission after trauma and ICU mortality. METHODS: We performed a retrospective analysis from a prospectively constituted database, of patients admitted to ICU after trauma at a single centre, over a 36 month period. According to cTnI plasma concentration at admission, patients were categorised into three groups: normal (<0.05 ng ml-1), intermediate (0.05-0.99 ng ml-1), or high concentration (≥1.0 ng ml-1). Associations of pre-hospital conditions or cTnI elevation and mortality were analysed by multivariate logistic regression. RESULTS: Among the 994 patients, 177 (18%) had cTnI elevation at ICU admission. Of this total, 114 (11%) patients died in the ICU. The cTnI release was an independent predictor of ICU mortality with a concentration-response relationship [odds ratio (OR) 4.90 (2.19-11.16) and 14.83 (4.68-49.90) for intermediate and high concentrations, respectively] and Day 2 mortality [OR 2.23 (1.18-5.80) and 7.49 (2.77-20.12) for intermediate and high concentrations, respectively]. The severity of thoracic trauma [OR 2.25 (1.07-4.55) and 3.23 (2.00-5.27) for Abbreviated Injury Scale scores 1-2 and ≥3, respectively], out-of-hospital maximal heart rate ≥120 beats min-1 [OR 2.22 (1.32-3.69)], and out-of-hospital shock [OR 2.02 (1.20-3.38)] were independently associated with cTnI elevation. CONCLUSIONS: Release of cTnI was an independent predictor of ICU mortality, suggesting that this biomarker can be used in daily practice for early stratification of the risk of ICU death. Thoracic trauma was strongly associated with cTnI elevation.

Femoral arterial and central venous catheters in the trauma resuscitation room.

BACKGROUND: Arterial and central venous femoral catheters (fAC-CVC) use during the initial management of severe trauma patients is not a standard technique in most trauma centers. Arguments in favor of their use are: continuous monitoring of blood pressure, safe drug administration, easy blood sampling and potentially large bore venous access. The lack of evidence makes the practice heterogeneous. The aim of the present study was to describe the use and complications of fAC-CVC in the trauma bay in two centers where they are routinely used. METHODS: This was a retrospective analysis of routine fAC-CVC use from two French trauma centers. All patients admitted directly to the trauma resuscitation room were included. Demographic, clinical and biological data were collected from the scene to discharge to describe the use of catheters during initial trauma management including infectious, mechanical and thrombotic complications. RESULTS: 243 pairs of femoral catheters were inserted among 692 patients admitted in both trauma centers. Femoral AC-CVC use was more frequent in critically ill patients with higher ISS 26 [17; 41] vs 13 [8; 24], p < 0.001(median [quartile 1-3]), severe traumatic brain injury (AIS head 1[0-4] vs 0[0-3], p < 0.001), lower systolic blood pressure, 92 (37) vs 113 (28) mmHg, p < 0.001 mean (standard deviation), lower haemoglobin on arrival, 10.9 (3) vs 13.3 (2.1) g/dL (p < 0.001), and higher blood lactate concentration, 4.0 (3.9) vs 2.1 (1.8) mmol/L (p < 0.001). In patients with fAC-CVC use time in the trauma room was longer, 46 [40;60] vs 30 [20;40] minutes (p < 0.05). In total 52 colonizations and 3 bloodstream infections were noted in 1000 catheter days. An incidence of 12% of mechanical complications and of 42% deep venous thromboses were observed. Of the latter none was associated with confirmed pulmonary embolism. CONCLUSION: Femoral AC-CVC appeared to be deployed more often in critically ill patients, presenting with shock and/or traumatic brain injury in particular. The observed rate of complications in this sample seems to be low compared to reported rates.

Use of aspirin and bleeding-related complications after hepatic resection.

BACKGROUND: The operative risk of hepatectomy under antiplatelet therapy is unknown. This study sought to assess the outcomes of elective hepatectomy performed with or without aspirin continuation in a well balanced matched cohort. METHODS: Data were retrieved from a multicentre prospective observational study. Aspirin and control groups were compared by non-standardized methods and by propensity score (PS) matching analysis. The main outcome was severe (Dindo-Clavien grade IIIa or more) haemorrhage. Other outcomes analysed were intraoperative transfusion, overall haemorrhage, major morbidity, comprehensive complication index (CCI) score, thromboembolic complications, ischaemic complications and mortality. RESULTS: Before matching, there were 118 patients in the aspirin group and 1685 in the control group. ASA fitness grade, cardiovascular disease, previous history of angina pectoris, angioplasty, diabetes, use of vitamin K antagonists, cirrhosis and type of hepatectomy were significantly different between the groups. After PS matching, 108 patients were included in each group. There were no statistically significant differences between the aspirin and control groups in severe haemorrhage (6·5 versus 5·6 per cent respectively; odds ratio (OR) 1·18, 95 per cent c.i. 0·38 to 3·62), intraoperative transfusion (23·4 versus 23·7 per cent; OR 0·98, 0·51 to 1·87), overall haemorrhage (10·2 versus 12·0 per cent; OR 0·83, 0·35 to 1·94), CCI score (24 versus 28; P = 0·520), major complications (23·1 versus 13·9 per cent; OR 1·82, 0·92 to 3·79) and 90-day mortality (5·6 versus 4·6 per cent; OR 1·21, 0·36 to 4·09). CONCLUSION: This observational study suggested that aspirin continuation is not associated with a higher rate of bleeding-related complications after elective hepatic surgery.

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines

PURPOSE: To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. METHODS: We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. RESULTS: We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. CONCLUSIONS: We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.

Pilot study of closed-loop anaesthesia for liver transplantation.

BACKGROUND: Automated titration of propofol and remifentanil guided by the bispectral index (BIS) has been used for numerous surgical procedures. Orthotopic liver transplantation (OLT) uniquely combines major changes in circulating volume, an anhepatic phase, and ischaemia-reperfusion syndrome. We assessed the behaviour of this automated controller during OLT. METHODS: Adult patients undergoing OLT were included in this pilot study. Consumption of propofol and remifentanil was calculated for each surgery period (dissection, anhepatic, and liver reperfusion phases). Arterial blood samples were collected at several time points to allow comparison of actual with calculated propofol and remifentanil concentrations. Data are presented as median [25th and 75th percentiles] or percentage (95% confidence interval). RESULTS: Thirteen patients were studied. System performance, defined as the percentage of time with BIS in the range 40-60, was 88% (86-94) of the total duration of anaesthesia. Propofol requirement was decreased during the anhepatic phase compared with the dissection phase (2.9 [1.9-5.0] mg kg(-1) h(-1) and 4.6 [3.5-8.1] mg kg(-1) h(-1); P<0.03) while remifentanil consumption was unchanged (0.11 [0.09-0.19] µg kg- (1) min(-1)). Bland-Altman analysis showed a weak concordance for propofol (bias of 0.7 µg ml(-1) and limits of agreement of -2.2 to +3.7 µg ml(-1)) and remifentanil (bias of 1.3 ng ml(-1) and limits of agreement -4.3 to +6.8 ng ml(-1)). No adverse events were reported during anaesthesia. CONCLUSIONS: This pilot study indicates that automated titration of propofol and remifentanil guided by the BIS is feasible during OLT.

Elaboration of a consensual definition of de-escalation allowing a ranking of ß-lactams.

Empirical broad spectrum antimicrobial therapy prescribed in life-threatening situations should be de-escalated to mitigate the risk of resistance emergence. Definitions of de-escalation (DE) vary among studies, thereby biasing their results. The aim of this study was to provide a consensus definition of DE and to establish a ranking of ß-lactam according to both their spectra and their ecological consequences. Twenty-eight experts from intensive care, infectious disease and clinical microbiology were consulted using the Delphi method (four successive questionnaires) from July to November 2013. More than 70% of similar answers to a question were necessary to reach a consensus. According to our consensus definition, DE purpose was to reduce both the spectrum of antimicrobial therapy and the selective pressure on microbiota. DE included switching from combination to monotherapy. A six-rank consensual classification of ß-lactams allowing gradation of DE was established. The group was unable to differentiate ecological consequences of molecules included in group 4, i.e. piperacillin/tazobactam, ticarcillin/clavulanic acid, fourth-generation cephalosporin and antipseudomonal third-generation cephalosporin. Furthermore, no consensus was reached on the delay within which DE should be performed and on whether or not the shortening of antibiotic therapy duration should be included in DE definition. This study provides a consensual ranking of ß-lactams according to their global ecological consequences that may be helpful in future studies on DE. However, this work also underlines the difficulties of reaching a consensus on the relative ecological impact of each individual drug and on the timing of DE.

Ultrasound assessment of gastric volume in critically ill patients.

PURPOSE: To assess the feasibility and validity of ultrasonographic measurement of gastric antral cross-sectional area (usCSA) in critically ill patients to predict gastric volume and the use of computed tomography (CT) as a reference to measure gastric volume. METHOD: This single-center, prospective, cross-sectional study included 55 critically ill patients who had an abdominal CT scan. usCSA measurements were performed within the hour preceding the CT scan. Gastric volumes were measured on the CT scan using semiautomatic software. The feasibility rate, performing conditions (% "good" and "poor"), internal and external validity of antral usCSA measurements, performed by an ICU physician, were assessed to predict gastric volume. RESULTS: Antral usCSA measurements were feasible in 95% of cases and were positively correlated with gastric volume measured by the CT scan when performed in "good" conditions (65%) (r = 0.43). There was good reproducibility of measurements (intraclass correlation coefficient of 0.97, CI 95% 0.96-0.99) and there was clinically acceptable agreement between measurements performed by radiologists and intensivists (bias -0.12 cm(2)). The receiver operating characteristic curve identified a cutoff value of 3.6 cm(2) that discriminated an "at-risk stomach" (volume >0.8 mL/kg) at a sensitivity of 76% and a specificity of 78%. CONCLUSIONS: Ultrasonographic measurement of antral CSA is feasible and reliable in the majority of critically ill patients. This technique could be useful to manage critically ill patients at risk of aspiration or with enteral feeding.

Risk factors associated with preoperative fecal carriage of extended-spectrum ß-lactamase-producing Enterobacteriaceae in liver transplant recipients.

OBJECTIVE: The aim of the study was to identify risk factors associated with pre-transplant fecal carriage of extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae in liver transplant recipients. PATIENTS AND METHODS: Over a 3-year period (January 2009-December 2011), 317 patients who underwent liver transplantation were screened preoperatively for fecal carriage of ESBL-producing Enterobacteriaceae. Risk factors for fecal carriage were investigated by univariate analysis and stepwise logistic regression. RESULTS: Of the 317 patients screened, 50 (15.7%) harbored an ESBL-producing isolate. Previous infection with an ESBL-producing organism had developed during the last 6 months in 20% of fecal carriers versus in none of the non-carriers. Other variables associated with fecal carriage were a model for end-stage liver disease score ≥25, pre-transplant stay in the intensive care unit ≥48 h, hospital stay ≥10 days in the last 6 months, a history of spontaneous bacterial peritonitis (SBP), exposure to a ß-lactam agent in the last month, and prophylaxis with norfloxacin. Independent predictors of fecal carriage in the multivariate logistic regression model were exposure to a ß-lactam agent in the month preceding transplantation (odds ratio [OR] = 7.8, confidence interval [CI] = 4-15.5, P < 0.001), and a history of SBP (OR = 2.4, CI = 1.1-4.9, P = 0.02). CONCLUSIONS: Previous infection with an ESBL-producing isolate, recent exposure to a ß-lactam agent, and a history of SBP are risk factors for preoperative fecal carriage of ESBL-producing Enterobacteriaceae in liver transplant recipients. Patients at risk of fecal carriage should receive intraoperative prophylaxis and, when necessary, empiric postoperative antimicrobial treatment that includes coverage for these organisms.

Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study.

BACKGROUND: Respiratory variation in pulse pressure (ΔPP) is commonly used to predict the fluid responsiveness of critically ill patients. However, some researchers have demonstrated that this measurement has several limitations. The present study was designed to evaluate the proportion of patients satisfying criteria for valid application of ΔPP at a given time-point. METHODS: A 1 day, prospective, observational, point-prevalence study was performed in 26 French intensive care units (ICUs). All patients hospitalized in the ICUs on the day of the study were included. The ΔPP validity criteria were recorded prospectively and defined as follows: (i) mechanical ventilation in the absence of spontaneous respiration; (ii) regular cardiac rhythm; (iii) tidal volume ≥8 ml kg(-1) of ideal body weight; (iv) a heart rate/respiratory rate ratio >3.6; (v) total respiratory system compliance ≥30 ml cm H2O(-1); and (vi) tricuspid annular peak systolic velocity ≥0.15 m s(-1). RESULTS: The study included 311 patients with a Simplified Acute Physiology Score II of 41 (39-43). Overall, only six (2%) patients satisfied all validity criteria. Of the 170 patients with an arterial line in place, only five (3%) satisfied the validity criteria. During the 24 h preceding the study time-point, fluid responsiveness was assessed for 79 patients. ΔPP had been used to assess fluid responsiveness in 15 of these cases (19%). CONCLUSIONS: A very low percentage of patients satisfied all criteria for valid use of ΔPP in the evaluation of fluid responsiveness. Physicians must consider limitations to the validity of ΔPP before using this variable.

Limits of agreement between measures obtained from standard laboratory and the point-of-care device Hemochron Signature Elite(R) during acute haemorrhage.

BACKGROUND: Rapid diagnosis of coagulopathy in the bleeding patient using point-of-care (POC) devices would be ideal. The Hemochron Signature Elite(®) (HC(®)) is a POC device that determines international normalized ratio (INR) and activated partial thromboplastin time (aPTT). The aim of the study was to evaluate the agreement for INR and aPTT between the HC(®) and standard laboratory values in acute haemorrhage. METHODS: This was a single-centre observational prospective study including patients with acute haemorrhage. Laboratory INR and aPTT were compared with simultaneous measurements performed with the HC(®). The diagnostic performance of HC(®) was determined; bias and limits of agreement were calculated according to the method of Bland and Altman. RESULTS: Seventy-two pairs of measurements from 39 patients were analysed. The bias between the INR-HC(®) and aPTT-HC(®) measurements and the central laboratory were 0.02 and -1.13, respectively. The Spearman's correlation coefficients for the INR-HC(®)/INR-lab and the aPTT-HC(®)/aPTT-lab were 0.68 and -0.29, respectively. Twenty-seven per cent of INR-HC(®) values and 89% of the aPTT-HC(®) values exceeded the predefined limits of agreement. The INR-HC(®) measurement identified patients with a central laboratory INR >1.5 with a sensitivity, specificity, and positive and negative predictive values of 83%, 70%, 76%, and 77%, respectively. CONCLUSIONS: The results showed a lack of agreement between the INR-HC(®) and the aPTT-HC(®) measurements and the standard laboratory in the context of acute haemorrhage. The INR-HC(®) showed moderate performance as a decision-making tool to detect coagulopathy in the context of acute haemorrhage.

[Organization of mechanical ventilation in French Intensive care units]. / Organisation de la ventilation artificielle dans les unités de réanimation en France.

OBJECTIVES: To clarify the procedures related to mechanical ventilation in the intensive care unit setting: allocation of ventilators, team education, maintenance and reference documents. STUDY DESIGN: Declarative survey. METHODS: Between September and December 2010, we assessed the assignment and types of ventilators (ICU ventilators, temporary repair ventilators, non-invasive ventilators [NIV], and transportation ventilators), medical and nurse education, maintenance of the ventilators, presence of reference documents. Results are expressed in median/range and proportions. RESULTS: Among the 62 participating ICUs, a median of 15 ventilators/ICU (range 1-50) was reported with more than one trademark in 47 (76%) units. Specific ventilators were used for NIV in 22 (35%) units, temporary repair in 49 (79%) and transportation in all the units. Nurse education courses were given by ICU physicians in 54 (87%) units or by a company in 29 (47%) units. Medical education courses were made by ICU senior physicians in 55 (89%) units or by a company in 21 (34%) units. These courses were organized occasionally in 24 (39%) ICU and bi-annually in 16 (26%) units. Maintenance procedures were made by the ICU staff in 39 (63%) units, dedicated staff (17 [27%]) or bioengineering technicians (14 [23%] ICU). Reference documents were written for maintenance procedures in 48 (77%) units, ventilator setup in 22 (35%) units and ventilator dysfunction in 20 (32%) ICU. CONCLUSIONS: This first survey shows disparate distribution of ventilators and practices among French ICU. Education and understanding of the proper use of ventilators are key issues for security improvement.

[French survey on perioperative nutrition in cirrhotic adult patients waiting for liver transplantation]. / Enquête sur l'évaluation et la prise en charge nutritionnelle des patients adultes cirrhotiques candidats à une transplantation hépatique.

OBJECTIVE: The European Society for Clinical Nutrition and Metabolism (EPSEN) guidelines on nutrition for liver disease patients has been recently updated. The aim of our study was to evaluate perioperative nutrition in cirrhotic patients waiting for liver transplantation (LT). STUDY DESIGN: Prospective electronic survey. A standardized questionnaire was sent to the anaesthesiologist of the 18 French adult LT centers. The questionnaire had closed-ended questions to evaluate nutritional practices in cirrhotic patients waiting for a LT. RESULTS: The response rate was 100%. Nutritional status of the cirrhotic patients waiting for LT was assessed by anaesthesiologists (12 centres) and/or hepatologists (11 centres) and more rarely by nutrition physician, dietetics or liver surgeons. Body mass index (13 centres), weight loss (10 centres), albuminemia (10 centres) were the most frequent items used to assess the nutritional status. Before LT, preoperative oral intakes were administered in undernourished patients in only 55% of the cases. Postoperatively, nutritional support was administered between day 1 and 3 after LT. CONCLUSION: Perioperative nutritional practices in cirrhotic patients waiting for LT are heterogeneous between centers, especially about nutrition assessment. Most of the centres did not follow the actual guidelines.

Fatal Escherichia coli skin and soft tissue infections in liver transplant recipients: report of three cases.

Gram-negative bacilli are unusual agents of skin and soft tissue infections. Most previous cases have been reported in cirrhotic or immunocompromised patients, including a single case in a liver transplant recipient. The present report describes 3 cases of fatal skin or soft tissue infections caused by Escherichia coli that occurred in the postoperative course of liver transplantation. The 3 patients were profoundly immunosuppressed as a result of pre-transplant cirrhosis and the postoperative administration of a potent immunosuppressive therapy. Skin and soft tissue infections developed within the first week after liver transplantation, while graft liver function was satisfactory. The 3 patients presented with fever and skin lesions with or without bullae. Despite prompt appropriate antibiotic therapy and surgical debridement, the outcome was rapidly fatal (24 h on average). E. coli was isolated from subcutaneous tissues in 2 cases and from several blood cultures in the third one. The 3 isolates belonged to distinct phylogenetic groups, and did not harbor most of the virulence factors usually reported in extraintestinal pathogenic E. coli isolates. Our report suggests that E. coli can cause severe skin or soft tissue infection in the postoperative course of liver transplantation. The onset of infection is very early and the outcome is extremely poor, despite prompt adapted medical and surgical treatment. Host factors, rather than E. coli bacterial virulence potential, appear to be the major determinants of severity in these patients.

Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan.

BACKGROUND: Whole-body CT scan is the cornerstone of trauma-related injury assessment. Several lines of evidence indicate that significant number of injuries may remain undetected after the initial hot report of CT. Missed injuries (MI) represent an important issue in trauma patients, for they may increase morbidity, mortality and costs. The aim of this study was to examine incidence and predictors of MI in trauma patients undergoing whole-body CT scan. METHODS: 177 CT scan performed upon admission of trauma patients during year 2005 were reviewed by a radiologist blinded to patient's initial data. MI was defined as injuries not written in the initial report. Patients with and without MI were compared to determine predictors of MI by multivariable analysis. RESULTS: 157 MI were diagnosed in 85 (47%) patients. MI was predominantly encoded AIS 2 (57%) or 3 (29%). Patients with MI had significantly higher SAPSII, higher ISS and were more frequently sedated. Age over 50 years (OR: 4.37, p=0.003) and ISS over 14 (OR: 4.17, p<0.0001) were independent predictors of MI. Median ISS after encoding MI was significantly higher than initial ISS (22 vs. 20 p<0.0001). After adjustment for severity, mortality and length of stay were not different between patients with or without MI. CONCLUSION: Trauma patients, especially aged and severe, experienced a high rate of missed injuries in the initial hot report which appeared to be predominantly minor and musculoskeletal, advocating a CT scan second reading.