Evaluation of the brain cellular damage during liver transplantations.

Background: Neuroinflammation in patients undergoing major surgery can lead to neuronal damage, and neuronal damage can be detected through the measurement of biochemical markers of brain damage. S100 beta (S100 ß), neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP) levels are considered good biomarkers to detect brain damage that emerged with neurotoxicity. Aim: To evaluate neuronal damage during liver transplantations. Materials and Methods: After approval of the ethics committee and patient consents, preoperative and postoperative cognitive functions of 33 patients undergoing liver transplantation were measured using the Mini Mental State Examination (MMSE), whereas simultaneous neuronal damage was evaluated through the measurement of S100ß, NSE, and GFAP levels. Results: There was no statistically significant difference between preoperative and postoperative MMSE. There was a statistically significant decrease in postoperative GFAP (P < 0.05) and a statistically significant increase in NSE (P < 0.05) compared to preoperative values. The decrease in S100ß (P > 0.05) level was statistically insignificant. Conclusions: Neuroprotective approaches in anesthesia protocol protect patients from brain damage during liver transplantation and prevent the development of postoperative cognitive dysfunction. Since the significant increase in NSE levels during liver transplantations was deemed to have been associated with causes other than neuronal damage, NSE should not be evaluated as a marker of brain damage in these operations.

The pharmacodynamic effects of rocuronium during general anesthesia in patients with type 2 diabetes mellitus.

AIM: The aim of this prospective study was to investigate whether the neuromuscular response to rocuronium is affected by the presence of type 2 diabetes mellitus. METHODS: Neuromuscular functions were measured after the administration of 0.6 mg/kg rocuronium with train-of-four stimulations in patients with type 2 diabetes mellitus (DM, N=14) and without diabetes mellitus (control, N=14) during isoflurane based general anesthesia. The onset time, clinical duration and recovery index of rocuronium were compared in the two groups. RESULTS: The mean onset time (136 +/- 40 vs 118 +/- 20 s), clinical duration (51 +/- 11 vs 48 +/- 11 min) and recovery index (6.0 +/- 2.5 vs 5.9 +/- 1.4 min) of the neuromuscular block were not significantly different between the DM and control groups, respectively (p>0.05). CONCLUSIONS: The present study has proven that the rocuronium-induced neuromuscular block was not affected in patients with type 2 diabetes mellitus during isoflurane based general anesthesia.

Right-sided diaphragmatic hernia after orthotopic liver transplantation: report of two cases.

Diaphragmatic hernia after OLT is a rare surgical complication. We here report successful diagnosis and treatment of two cases with right-sided diaphragmatic hernia developed after OLT both utilizing left-sided allografts. Combination of factors related to the surgical techniques and patient characteristics might explain the pathophysiology behind the diaphragmatic hernias following liver transplantation. Respiratory as well as non-specific gastrointestinal symptoms may be hints for an overlooked diaphragmatic hernia after liver transplantation. Diaphragmatic hernia should be added to the list of potential complications of liver transplantation for prompt diagnosis and appropriate treatment.

Effects of cardiac valve dysfunction on perioperative management of liver transplantation.

OBJECTIVE: Our aim was to investigate the effects of cardiac valve dysfunction on perioperative management of orthotopic liver transplantation (OLT) among a retrospective cohort. PATIENTS AND METHODS: Three hundred forty-six patients underwent echocardiographic (ECHO) examination prior to OLT. Data of patients with valvular dysfunctions were compared to subjects with normal ECHO. We evaluated patient characteristics, operation variables, hemodynamic course, blood products, fluid and drug requirements, extubation, and mortality rates. RESULTS: Ninety-five patients (27.5%) with cardiac valve dysfunction were classified as mitral valve insufficiency (MVI; n = 32), tricuspid valve insufficiency (TVI; n = 23), or both MVI and TVI (n = 40). One hundred fifty-two patients displayed normal ECHO examinations (control). Ninety-nine patients with other pathologies were excluded from the study. Systemic vascular resistance was significantly lower among the MVI group, and cardiac output (CO) significantly higher in the MVI and both MVI and TVI groups compared with controls. More MVI and both MVI and TVI patients required epinephrine compared with controls. The number of patients who required blood transfusion was higher in the MVI than the control group (P < .05). Patient characteristics, end-stage liver failure scores, duration of operations, hemodynamic variables, incidence of postreperfusion syndrome, mean doses of ephedrine and epinephrine, red blood cells, fresh frozen plasma and fluid requirements, number of patients extubated immediately after surgery, and mortality rates were not different between the groups. CONCLUSIONS: Our study demonstrated that cardiac valve dysfunction may be associated with end-stage liver disease among patients undergoing OLT. Patients with MVI or both MVI and TVI required more care in perioperative management.

Cytokine gene polymorphism and postreperfusion syndrome during orthotopic liver transplantation.

UNLABELLED: The molecular basis underlying the clinical response to acute liver stress remains to be clarified. Postreperfusion syndrome (PRS) occurring after the meeting of grafted liver with the recipient blood is characterized by hemodynamic instability that develops immediately after reperfusion of an orthotopic liver transplantation (OLT). Cytokines have a role during PRS. The aim of this study was to evaluate the role of some cytokine gene polymorphisms on PRS in patients. MATERIALS AND METHODS: Forty-six patients who underwent OLT were divided into two groups: with versus without PRS. Cytokine genotyping using patient blood was determined by the PCR-SSP method. RESULTS: Liver transplant patients as a whole are usually characterized as low producers of tumor necrosis factor (TNF)-alpha and interleukin (IL)-10, high producers of transforming growth factor (TGF)-beta1 and IL-6 and intermediate producers of interferon (IFN)-gamma. However no significant relationship was shown between the development of PRS and cytokine gene polymorphisms of TNF-alpha (-308 G/A), TGF-beta1 (C/T codon 10, C/G codon 25), IL-10 (-1082 G/A, -819 T/C, -592 A/C), IL-6 (-174 G/C), or IFN-gamma (+874 A/T). CONCLUSION: It seemed that our limited data did not substantiate a role of certain cytokine gene polymorphisms on PRS occurence during OLT. A larger study population may be required to examine this relationship.

Successful resuscitation of cardiac arrest due to postreperfusion syndrome during orthotopic liver transplantation: a case report.

A patient with alcohol induced end-stage liver disease developed cardiac arrest immediately after reperfusion during orthotopic liver transplantation. In our case, advanced age of the patient, alcohol-related severe liver disease with high ASA score, and myocardial dysfunction, combined with acute metabolic and hemodynamic changes throughout the surgery may have contributed to the development of postreperfusion syndrome resulting in cardiac arrest. Our patient required a total of 5 mg epinephrine, 200 mg lidocaine, 100 mEq NaHCO3, and 40 mEq calcium gluconate together with direct cardiac compressions and ventilation enriched 100% oxygen to regain sinusoidal rhythm. In conclusion, during severe postreperfusion syndrome, the collaboration between the surgical and anesthesia teams is crucial to overcome cardiac arrest. In an open abdomen, direct cardiac compressions through the transdiaphragmatic pericardial window instead of chest compressions were important to restore effective circulation during advanced life support.

Cytokine gene polymorphism and early graft rejection in liver transplant recipients.

Cytokines, which play important roles in allograft rejection, show variable production among individuals. These variations may be related to genetic polymorphisms within the regulatory regions of the cytokine genes. We investigated the association between the role tumor necrosis factor alpha (TNF-alpha), transforming growth factor-beta (TGF-beta), interferon gamma (IFN-gamma), interleukin (IL)-10 and IL-6 gene polymorphisms and early graft rejection among liver transplant recipients. Forty-three liver transplant recipients enrolled in this study were divided into 2 groups based on events in the first 2 months posttransplantations, namely, those experiencing at least 1 rejection episode (n = 26) or those without any episode (n = 17). The allele or genotype frequencies of cytokine gene polymorphisms showed no difference between liver recipients with or without nonrejection. In conclusion, there was no significant correlation between early graft rejection and cytokine gene polymorphism of TNF-alpha, TGF-beta, IL-10, IL-6, and IFN-gamma in liver transplant recipients.

Anesthetic management and complications in living donor hepatectomy.

A total of 112 living donor hepatectomies (LDHs) performed from October 1999 to April 2003 at Ege University Hospital Organ Transplantation Center were reviewed and perioperative anesthetic courses and complications were determined. There was no perioperative mortality. Mean duration of operations was 333 +/- 77 minutes (range, 160 to 540 minutes) for right lobectomies and 277 +/- 88 minutes (range, 150 to 500 minutes) for left lateral segment plus left lobe operations. The remnant liver volume ratios of the patients was 0.58 +/- 0.16 (range, 0.30 to 0.91) after harvesting. Crystalloids, colloid infusions, and transfusions aimed to keep hematocrit >25%, central venous pressure (CVP) <5 mm Hg and to maintain a urine output >1 mL/kg(-1) while nitroglycerin was infused (0.5 to 2.0 microg/kg(-1)h(-1)) when needed to allow fluid infusions freely without increasing the CVP values. No transfusion was needed for 91 patients (81%) and 21 right lobectomy patients needed transfusion of blood products. Initial mean hematocrit of 38.9 +/- 4.9% (range, 27% to 50%) for all patients was found 31.5% +/- 5% (21% to 44%) at the end of the operation. Albumin blood levels averaged 4.27 +/- 0.49 g/dL(-1) at the beginning and 3.28 +/- 0.45 g/dL(-1) after hepatic resection. Perioperative complications were one air embolism, postoperative systemic inflammatory response syndrome in one patient, transient but severe hemoglobinuria due to a predonated autologous blood transfusion in another, prolonged recovery for neuromuscular blocker overdose in one patient, and postoperative atelectasis in three patients, two of whom had pneumonia later while two other patients had pleural effusions. One required a drainage. Living donor hepatectomies were performed with acceptable complications in anesthetic management during this study. The operation provides us with an optimal liver segment without resulting in mortality.

Causes of postreperfusion syndrome in living or cadaveric donor liver transplantations.

OBJECTIVE: The postreperfusion syndrome (PRS) occurrence was evaluated in patients undergoing liver transplantation in our institution to determine the relationship between PRS and associated variables. METHODS: Of the 185 consecutive liver transplants, pediatric patients, patients with uncompleted data or retransplantations were excluded. The remaining 145 adult patients having 77 cadaveric and 68 living donor right lobe liver transplantations were studied. PRS was defined as a decrease in mean arterial pressure >30% below the baseline value. Logistic regression was used for statistical analyses. A P value <.05 was considered as significant. RESULTS: Total rate of PRS occurrence was 48.9% (71 patients) for the 145 patients. Logistic regression analyses revealed a significant relationship between the PRS and four of the variables: shorter duration of the anhepatic period, higher mean calcium requirement, higher mean heart rate difference from anhepatic to reperfusion period and lower central venous pressure at the dissection period during operations (P <.05). We could not demonstrate any significant effect of the operation type-surgical technique and duration of operations, blood and fresh frozen plasma volume transfused, demographic variables of the recipients, donor liver factors, other haemodynamic and metabolic variables at specific time periods (P >.05). CONCLUSIONS: In conclusion, it is important that PRS does not seem to occur in a predictable manner in this study except for the increased calcium requirements during the operations in PRS experienced patients. The clinical parameters as graft ischemia time, the type of the operation, demographic variables of the recipient, hemodynamic or metabolic variables and transfusion needs during the operations seemed to have no contribution to PRS occurrence.

Acute amitraz intoxication in human.

OBJECTIVE: To review the clinical profiles and therapies instituted for patients with acute amitraz intoxication. DESIGN: Retrospective study. SETTING: Multidisciplinary intensive care unit (ICU) of a university hospital. PATIENTS: Ten patients admitted to the ICU of Ege University Hospital. RESULTS: Ten patients between 4 and 34 years of age were evaluated. The intoxication was the result of a suicide attempt in five cases and accidental in the rest. Altered consciousness, nausea, vomiting and dizziness were the common initial symptoms. The major clinical findings in the ICU were somnolence, coma, miosis, mydriasis, bradycardia, respiratory failure requiring mechanical ventilation, and hypo- and hyperthermia. Blood glucose level was increased significantly in three cases and urinary output was increased in two. The length of stay was between 2 and 5 days. CONCLUSION: The signs and symptoms of acute amitraz intoxication appear rapidly and become established within hours. The initially severe clinical situation improves fast. Cases of this rare mode of intoxication should be carefully followed and treated in the ICU.