Challenges in preventing pyelonephritis in pregnant women in Indigenous communities.

AIM: To measure the quality of antenatal care in rural and remote regions of the Northern Territory, using asymptomatic bacteruria as an indicator. BACKGROUND: Indigenous Australian women and their babies have a greater frequency of adverse outcomes in pregnancy than their non-Indigenous counterparts. It is well established that asymptomatic bacteriuria may have serious outcomes in pregnancy, including an increased risk of pyelonephritis and a strong association with preterm and low birth weight delivery. Ensuring good quality antenatal care can reduce the individual risks of pregnancy for mothers and their babies. In the Northern Territory there are well established guidelines for antenatal care in rural and remote Indigenous communities. These are documented in the Women's Business Manual. Audit and feedback is one method that has been shown to have a small to moderate effect in changing clinician behaviour, in this case improving compliance with guidelines. METHODS: A retrospective chart audit of antenatal clients was conducted at 10 rural and remote primary health care clinics in the Northern Territory, Australia. The audit reviewed all the available charts (n = 268) of pregnant women, from the participating communities, who gave birth in 2002 or 2003. The diagnosis and management of asymptomatic bacteriuria was chosen as the indicator of quality antenatal care, as it is one of five areas of antenatal care where there is evidence that appropriate management improves outcomes. The quality of care was measured against the local guidelines, the Women's Business Manual. RESULTS: Women frequently had urine tests with where the dipstick showed an abnormal result, with 75% (95% CI [0.70,0.80]) of women having at least one episode of abnormal urinalysis during pregnancy. Six hundred and twenty episodes of abnormal urinalysis in pregnancy were identified. The incidence of bacteriuria at first visit was 16%, (95%-confidence interval = 95% CI [0.10, 0.21]). Compliance with the guidelines was poor. Fifty-six percent (95% CI [0.52,0.60]) of those samples testing positive on urinalysis were not sent to pathology for microscopy and culture, as recommended in the guidelines. Of those with a positive culture, 32% (95% CI 0.28,0.39) were appropriately treated with antibiotics. When antibiotics were given, good compliance of 82% (95% CI 0.76,0.87) with antibiotic guidelines was demonstrated. The positive predictive value of dipstick urinalysis in diagnosing asymptomatic bacteriuria was low in this study at 33.5%. There were 13 episodes of confirmed or probable pyelonephritis. No women with recurrent urinary tract infections were followed up according to protocol. CONCLUSION: Aboriginal women have worse pregnancy outcomes than the non-Indigenous population of Australia. Pyelonephritis is a preventable condition in pregnancy. In these rural and remote communities, pyelonephritis has not been prevented due, in part, to a failure to follow the local guidelines. Structural problems were identified and need to be addressed in order to improve compliance with guidelines and hence pregnancy outcomes for rural and remote Indigenous women.

Pathophysiological mechanisms of postrevascularization hyperkalemia in orthotopic liver transplantation.

The underlying mechanisms of hyperkalemia occurring immediately after revascularization in orthotopic liver transplantation (OLT) are unknown. We investigated the possible pathophysiological mechanisms of hyperkalemia in relation to the donor and recipient. The study included 64 consecutive patients undergoing OLT. Recipients were divided into two groups: Group 1 consisted of 47 patients with serum K(+) concentration <5.5 mmol/L at 1-min postrevascularization, and Group 2 consisted of 17 patients with serum K(+) exceeding 5.5 mmol/L. Increased serum K(+) concentration, more progressive metabolic acidosis, and decreased mean arterial blood pressure and cardiac index during the anhepatic phase were recognized in Group 2. Multiple regression analysis showed that cardiac index, serum lactate, and serum K(+) concentration during the anhepatic phase were independent and significant factors that could predict serum K(+) concentration 1-min postrevascularization. Hyperkalemia at 1-min postrevascularization did not correlate with the extent of preservation injury of the graft liver (represented by the peak value of aspartate aminotransferase measured within the first 72 h after OLT) or the duration of cold ischemia. We conclude that hyperkalemia occurring immediately after revascularization in OLT is mainly caused by metabolic acidosis as a result of insufficient cardiac output during the anhepatic phase.

[Causes of renal dysfunction during the anhepatic phase in patients for orthotopic liver transplantation and their postoperative renal function].

This study was carried out to clarify causes of renal dysfunction during the anhepatic phase in orthotopic liver transplantation (OLT) with venovenous bypass and to show how the deterioration impacted on postoperative renal function. The 44 consecutive patients with normal preoperative renal function who underwent OLT in Royal Prince Alfred Hospital were classified into two groups according to creatinine clearance (Ccr) during the anhepatic phase. Group 1 consisted of 27 patients whose Ccr levels levels were kept above 60 ml.min-1.m-2 and group 2 consisted of 17 patients under 60 ml.min-1.m-2. In group 2, preoperative International Normalized Ratio for prothrombin was higher and blood transfusion volume before revascularization was significantly lager than group 1. There were significant differences in haemodynamics just before revascularization (mean arterial pressure 95 +/- 14 vs 83 +/- 14 mmHg, pulmonary artery wedge pressure 16 +/- 5 vs 11 +/- 5 mmHg, cardiac index 4.6 +/- 1.3 vs 4.0 +/- 0.9 l.min-1.m-2, group 1 vs group 2, mean +/- SD, P < 0.05). Serum creatinine levels in group 2 were significantly higher postoperatively. It is suggested that bleeding due to insufficient preoperative coagulability caused haemodynamic instability which deteriorated renal function during the anhepatic phase and the deterioration impacted on postoperative renal function.

Retrospective review of 100 cases of endoluminal aortic stent-graft surgery from an anaesthetic perspective.

One hundred cases of endoluminal aortic stent surgery were retrospectively reviewed and analysed with respect to outcome. The overall mortality rate was consistent with standard rates for open surgical repair. One hundred per cent of patients who developed multiorgan failure died (7), as did 78% of those who developed acute renal failure (9), and 55% of those who had a serum creatinine rise greater than 100 mumol/l (9). Patients given mannitol had an increased incidence of a serum creatinine rise of greater than 100 mumol/l, at 16% versus 4% for those not given mannitol. Patients with documented intra- or postoperative anaemia (Hb < or = 80 g/l) had a mortality rate of 22% compared to 5% for non-anaemic patients. The mortality rate increased from 3% to 15% if the procedure took more than four hours. The anaesthetic requirements for this new type of surgery are outlined and discussed with respect to these results. The surgical technique is summarized.

Intentional asystole during endoluminal thoracic aortic surgery without cardiopulmonary bypass.

We describe in three patients the use of adenosine to arrest the heart without cardiopulmonary bypass during endoluminal repair of thoracic aortic aneurysms. The pharmacology of adenosine, a purine nucleoside present in all cells, is reviewed briefly, with special reference to its use in causing transient asystole, which is required for successful surgical expansion of the graft stent in the thoracic aorta.

A liver transplantation technique in a patient with a thrombosed portal vein and a functioning renal-lieno shunt.

A liver transplant technique is described in a patient with a thrombosed portal vein and a functioning surgically created renal-lieno shunt. Permanent portal inflow to the graft was provided by division of the left renal vein (LRV) at its junction with the inferior vena cava and anastomosis of the LRV end-to-end with the donor portal vein. Although this results in splanchnic blood traversing a 360 degree roundabout from the superior mesenteric vein via the splenic and disconnected left renal veins to the donor portal vein, the anastomosis lay well and the procedure was successful.

Case report: delayed resolution of severe pulmonary hypertension after isolated liver transplantation in a patient with cirrhosis.

Pulmonary hypertension is now recognized to be a rare association of liver disease and portal hypertension. This report describes the slow resolution of symptomatic pulmonary hypertension in a 33-year-old woman with cirrhosis who underwent isolated liver transplantation. The patient survived the surgery and perioperative period without significant haemodynamic compromise. After liver transplantation, the patient was monitored with regular Doppler echocardiography. By 27 months the pulmonary hypertension had almost completely resolved. This observation is important, as it suggests that patients with severe pulmonary hypertension who survive the perioperative period may have an excellent outcome, although resolution may be slow.

Effects of total hepatectomy: studies in a porcine model.

The effects of total hepatectomy in a porcine model were studied. A portacaval shunt was constructed prior to hepatectomy, and the excised segment of inferior vena cava was replaced with a Dacron graft as soon as the liver had been removed. While the vena cava was clamped, venous return from the lower body to the heart was maintained using an extracorporeal veno-venous bypass system. The results of the study revealed that surprisingly few haemodynamic, biochemical or coagulation disturbances occur within the first 5 h following total hepatectomy in the pig, an animal with remarkably close anatomical and physiological similarities to man. In the anhepatic period which follows total hepatectomy during clinical liver transplantation, the situation is more complex, because pre-existing liver disease and portal hypertension, as well as major blood loss, often provide other reasons for metabolic and haemodynamic instability and coagulation disorders. The possible relevance of the findings in this large animal model to events that occur following total hepatectomy in the clinical situation is discussed.

The first five years' clinical experience of the Australian National Liver Transplantation Unit.

OBJECTIVE: To report the first five years' clinical experience of the Australian National Liver Transplant Unit. PATIENTS: Three hundred and seventy patients were referred--292 adults (79%) and 78 children (21%). The major causes of liver failure in the adults were chronic active hepatitis (25%), primary biliary cirrhosis (12%), primary sclerosing cholangitis (12%), alcoholic cirrhosis (9%) and malignancy (9%). Ten per cent of patients were referred in fulminant hepatic failure. In children, the major causes were biliary atresia (40%) and inborn errors in metabolism (27%). RESULTS: Two hundred and sixty-three patients (71%) were accepted for transplantation. Of 158 (43%) accepted for early transplantation, 22 (14%) died before a donor became available. Four hundred and forty-three suitable organ donors were referred. One hundred and twenty-six patients, including 32 children (25%), received 137 grafts. Three patients with renal failure due to hyperoxaluria type 1 received concurrent renal grafts. Ninety-two patients survived (73%). For all recipients, one-year survival was 75%. Two, three and four-year survivals were 69%. One to four-year survivals for adults with benign conditions were 77%, contrasting with results for those with hepatic malignancy (40% one-year survival). Children weighing more than 8 kg had good outcomes whether they received whole grafts or reduced-size grafts (83% one to five-year survival in both cases). Infants weighing less than 8 kg who received reduced adult grafts did significantly worse (37% one to-five year survival, P less than 0.05). Thirteen (87%) of 15 patients with fulminant hepatic failure who received grafts survived. Five of these patients were given ABO-incompatible grafts and two subsequently required retransplantation. All three patients with concurrent renal and hepatic grafts survived. Rehabilitation of survivors was excellent with 95% of adults and 100% of children pursuing normal activities. Only three grafts (2%) failed with primary non-function, all in infants because of graft infarction. Graft survival was significantly worse (P less than 0.01) in patients with a positive result to a direct cross match test against the donor. CONCLUSIONS: The need for liver transplantation in Australia is approximately eight per million of population per year. More donor offers are required to prevent deaths of patients on the waiting list. Reduced-size livers are successful for children and have alleviated considerably the critical shortage of paediatric donor livers. Successful treatment by liver transplantation can now be achieved in more than 80% of patients with non-malignant liver disorders including those with fulminant hepatic failure not responding to conservative therapy.

Use of the cell saver during elective abdominal aortic aneurysm surgery--influence on transfusion with bank blood. A retrospective survey.

One hundred and two patients undergoing elective abdominal aortic aneurysm repair and admitted to ICU at RPAH in 1989/90 were studied. In forty patients a cell saver was used during the operative procedure (Group CS) while in the remaining sixty-two patients intraoperative blood loss was drained and discarded conventionally (Group NCS). Preoperative ASA grade and postoperative APACHE score were similar in these two groups. The amount of bank blood transfused intraoperatively was less in Group CS than in Group NCS (0.6 +/- 0.2 vs 3.3 +/- 0.3 units) (mean +/- SEM) (P less than 0.0001). The total amount of bank blood transfused during hospital admission was also less in Group CS (1.5 +/- 0.4 vs 4.8 +/- 0.4 units, P less than 0.0001). Of Group CS, 22 patients (55%) received no bank blood compared to two patients (3%) in Group NCS. There was no difference between the groups with respect to postoperative haemoglobin and creatinine levels. ICU stay was similar in both groups. We conclude that use of the cell saver reduces perioperative bank blood transfusion in elective abdominal aortic surgery.

Liver transplantation: an Australian experience.

During a 4 and a half-year experience, 283 patients were referred to the Australian National Liver Transplant Unit. Sixty (21%) were children. The major causes of liver failure in the adults were chronic active hepatitis (27%), primary biliary cirrhosis (13%), primary sclerosing cholangitis (12%), fulminant hepatic failure (9%), alcoholic cirrhosis (9%), and malignancy (9%). In the children they were biliary atresia (43%) and inborn errors of metabolism (18%). One hundred and ninety-seven (69%) were accepted for liver transplantation. Of 111 (39%) accepted for early transplantation, 18 (16%) died before a donor became available. There were 319 possible organ donors. Ninety patients (24 of them children) received 100 grafts. Sixty-three (70%) patients survived. For all recipients, 1-year survival was 73%. Two-, 3- and 4-year survivals were 67%. One- to 4-year survivals for adults with benign conditions were 76%, contrasting with results for those with hepatic malignancy (20% 1-year survival). Children weighing greater than 8 kg did well whether they received whole grafts (80% 1- to 4-year survival) or reduced grafts (75% 1- to 4-year survival). Infants weighing less than 8 kg who received reduced adult grafts did significantly worse (20% 1- to 4-year survival). All 8 (100%) patients with fulminant hepatic failure who received grafts survived, including 3 who received ABO-incompatible grafts, though 2 of these subsequently required retransplantation. Rehabilitation of survivors was excellent with 91% of adults and 94% of children pursuing normal activities. Only 2 (2%) grafts failed with primary nonfunction, both in infants because of infarction. Graft survival was significantly worse (p less than 0.01) in patients with a positive direct crossmatch test against the donor. We calculate that the need for liver transplantation in Australia is approximately 7 per million of population per year. Increased donor offers are required to avoid deaths of patients on the waiting list. Reduced-size adult livers are successful for children and have alleviated considerably the critical shortage of pediatric donor livers. Liver transplantation is a highly satisfactory treatment for patients with benign liver disorders but not for those with malignant conditions. Patients with fulminant hepatic failure not responding to conservative therapy should be treated by liver transplantation. In this and other urgent circumstances, an ABO-incompatible liver may be lifesaving though retransplantation with an ABO-compatible liver may subsequently be required. The results of liver transplantation for nonmalignant conditions have improved steadily with clinical experience, with 1- and 2-year patient survivals during the past 28 months of 85%.

Decision-making in 100 patients referred to the Australian National Liver Transplantation Unit.

One hundred patients were referred to the Australian National Liver Transplantation Unit between January 1986 and August 1987. The commonest disorders for referral were chronic active hepatitis in adults (22 cases), fulminant hepatic failure (14), primary biliary cirrhosis (PBC) (12) and primary sclerosing cholangitis (PSC) (10). Of the 100 patients 31 were activated for transplantation while 35 were deferred and 34 were found to be unsuitable. The decision-making in these patients is discussed according to disease category. Timing of transplantation in PBC and PSC seemed clearcut, with 50% of referred patients being activated. However, major difficulties in timing of transplantation were found, particularly in patients with chronic active hepatitis (CAH) and fulminant hepatic failure (FHF). Of 36 patients with CAH (22) or FHF (14) only five were put on the active waiting list and only two were transplanted. Overall, 25 of the 31 patients underwent orthotopic liver transplantation, with 16 alive two-30 months later.

Physiological changes during liver transplantation.

Thirteen patients who received liver transplants at the National Liver Transplant Unit between January 1986 and March 1987 were studied with extensive monitoring and frequent intraoperative biochemical and haematological profiles. Anaesthetic technique was standardised for all patients. Retrospective analysis of this data confirms that patient homeostasis is most disturbed at the time of revascularisation of the donor liver. In this series, revascularisation was associated with marked changes in all measured haemodynamic parameters (arterial blood pressure, cardiac index, heart rate, and filling pressures). There was also a significant fall in pH with revascularisation, followed by a gradual rise during the final phases of the operation. Potassium levels often rose sharply with revascularisation but then decreased during the rest of the operative period. Ionised calcium levels did not change significantly at any stage; however, all patients were given calcium intraoperatively. Coagulation profiles were often abnormal preoperatively. The transplant procedure was associated with further abnormalities in both coagulation and fibrinolysis. Patient temperatures were maintained at normal levels throughout the procedure.

Liver graft revascularization by donor portal vein arterialization following "no touch" donor hepatectomy.

Unsatisfactory immediate function of the transplanted liver together with technical complications contribute to a persisting early mortality for hepatic transplantation in the 20% range. We report our initial clinical experience with methods, one not previously used clinically, that resulted in uniformly well-functioning liver grafts in 11 patients and contributed to a satisfactory success rate for the procedure. Donors were heart-beating. During the donor operation all manipulations of the liver were avoided until after cold preservation, achieved by external cooling at the same time as circulatory interruption, donor exsanguination and perfusion of the liver with cold oxygenated fluid of "extracellular" type. The organs were then gently dissected. At transplantation the livers were revascularized with arterial blood shunted from the recipient iliac artery to the graft portal vein after completion of the suprahepatic IVC anastomosis. The infrahepatic IVCs and hepatic arteries were then joined, the iliac artery shunts discontinued and the portal veins joined. Total ischaemic intervals for the allografts were 3 1/2-8 (average 5). Anhepatic intervals were 1-2 1/4 (average 2). The arterio-portal shunts were operating for 18-85 (mean 46) min. Blood loss and haemodynamic, acid-base and electrolyte abnormalities at revascularization were minimal. All grafts secreted bile immediately and all parameters reflected continuing improvement of liver function thereafter. Nine patients (82%) are alive between 4 and 18 (mean 11) months after transplantation. We conclude that these methods offer effective avoidance of serious organ damage during donor hepatectomy and preservation, reduced allograft ischaemic interval and reduced recipient anhepatic time. They result in avoidance of blood loss at the time of revascularization, together with minimal haemodynamic, acid-base or biochemical changes. In addition, they allow the surgeon to perform and test all anastomoses without time constraints, provide the capability to deal with unexpected complications, and assure good early graft function.