[Cardiac perforation and tamponade during TIPS placement]. / Un cas de tamponnade cardiaque par perforation du ventricule droit au décours immédiat d'une pose de TIPS.

A patient developed an acute severe haemodynamic compromise immediately after a transjugular intrahepatic portosystemic shunt (TIPS) procedure for intractable ascites. Rapid clinical and echographic evaluation disclosed pericardial blood and cardiac tamponade, probably due to right heart perforation from guidewire and catheter manipulation. Needle drainage of pericardial fluid restored the haemodynamic status. A right ventricular perforation was then successfully treated (sternotomy and closure of right ventricle perforation) and the patient survived. Cardiac tamponade should be considered in the differential diagnosis of patients who develop hypotension and haemodynamic impairment during or immediately after TIPS placement.

Analgesic efficacy and safety of nefopam vs. propacetamol following hepatic resection.

In order to compare the morphine-sparing effect, analgesic efficacy and tolerance of nefopam and propacetamol given at their highest recommended doses, 120 patients undergoing elective hepatic resection were randomly assigned to receive postoperative intravenous patient-controlled analgesia with morphine alone, or in combination with nefopam (20 mg.4 h-1) or propacetamol (2 g.6 h-1). Compared with the control group (43 [7-92] mg), median [range] cumulative morphine consumption for 24 h after the study started was halved in the nefopam group (21 [3-78] mg, p <0.001) and 20% lower in the propacetamol group (35 [6-84] mg, p = 0.15). Analgesia was superior in the nefopam group despite the lower morphine consumption. Adverse effects were comparable in the three groups, except for significantly more nausea in the control group (39% vs. 17 and 26% in the nefopam and propacetamol groups, respectively) and more sweating in the nefopam group (17% vs. 0 and 3% in the control and propacetamol groups, respectively). Overall patient satisfaction was better (p < 0.001) in patients given nefopam (97%) than those receiving morphine alone (82%) or propacetamol (74%).

How to stabilize the level of ionized calcium and citrate during plateletpheresis.

BACKGROUND AND OBJECTIVES: Citrate reactions are uncomfortable and potentially dangerous to apheresis donors. Reduction of citrate increases comfort, but may lead to platelet clumping. MATERIALS AND METHODS: We describe a protocol for stepwise reduction of the volume of ACD-A injected during plateletpheresis. This protocol has been carried out in 45 healthy donors with the Cobe 2997 (Cobe) cell separator, and in 35 with the Fenwal-CS 3000 (CS). RESULTS: Using this protocol, during the first hour of platelet collection, ionised calcium decreased on average by 18% for CS and by 18.4% for Cobe. During the second hour, Ca2+ and citrate ion concentration did not change with either Cobe or CS (about 65% of citrate ion load is eliminated). We observed mild signs of neuromuscular hyperexcitability in only 22% and 28% of donors with Cobe and CS, respectively. We also found a significant reduction of phosphate ions (p < 0.0001) at the end of the procedures. CONCLUSIONS: With this stepdown citrate reduction protocol, we obtained a significant reduction of injected citrate without the complication of platelet clumps.

Comparative effects of small and large aprotinin doses on bleeding during orthotopic liver transplantation.

Large prophylactic doses of aprotinin efficiently reduce blood loss during orthotopic liver transplantation (OLT). Small doses of aprotinin are usually used to treat fibrinolysis. However, no studies have investigated the benefit of prophylactic administration of a smaller dose of aprotinin during liver transplantation. We compared two methods of aprotinin therapy on transfusion outcome in liver transplant patients in a prospective study of 199 patients undergoing OLT who were randomized to large or small prophylactic doses of aprotinin during the transplant procedure. In the large-dose group (n = 94) an initial dose of 2,000,000 kallikrein inactivation units (KIU) was followed by infusion of 500,000 KIU/h until the patient's return to the intensive care unit. In the small-dose group (n = 95), an initial dose of 500,000 KIU was followed by an infusion of 150,000 KIU/h. Outcome measurements included intraoperative transfusion requirements (packed red blood cells, fresh frozen plasma, platelets, intraoperative salvage) and postoperative hematologic values. There were no differences in transfusion requirements in the two groups of patients. Patients treated with low-dose aprotinin had slightly higher postoperative fibrinogen concentrations. Large-dose aprotinin therapy does not appear to offer additional benefit compared to low-dose aprotinin administration.

[What is the method of choice for hemodynamic monitoring in liver transplantation?]. / Quel monitorage hémodynamique lors des transplantations hépatiques?

Orthotopic liver transplantation requires close hemodynamic monitoring. Technological advances provide new possibilities of improving this monitoring. The most recent devices are the mixed venous oxygen saturation catheter, which gives continuous SVO2 values, and the right ejection fraction catheter used discontinuously. Our experience of 100 liver transplantations has enabled us to investigate the advantages of these catheters over the conventional Swan Ganz catheters.

[Safety of donors, quality of products, how much to reduce the quantity of citrate]. / Sécurité des donneurs, qualité des produits jusqu'où diminuer la quantité de citrate.

We examined 1,053 blood samples from 48 donors, for the effect of gradual reduction of citrate. We observed that: 1--Platelet count does not show any significant variation between 1/8 to 1/18 ratio. 2--In 13.3% of the cases, platelet clumping starts at 1/18 ratio. 3--There was no significant variation of the thrombin plasma level between 1/8 to 1/16 ratio (by measuring thrombin/ATIII complex). Our results show clearly that we can reduce the citrate ratio to 1/14 without expecting any adverse effect. Therefore we designated 1/14 as the security ratio. Parallel to this we also found that the average level +/- SD of ionized calcium is 100 +/- 10 muMol at 1/14 ratio.

Emergency orthotopic liver transplantation in two patients using one donor liver.

Because of its anatomy, the liver can be divided into two hemilivers suitable for use as two grafts for liver transplantation. The line of division is the main scissure, giving the right hemiliver (segments 5-8) and the left hemiliver (segments 2-4). Segment 1 (caudate lobe) has to be resected. The vessels are divided between the two grafts: the vena cava remains on the right; on the left, the left hepatic vein is sutured into the vena cava of the recipient, which is retained intact. The left graft retains only the left branch of the portal vein, the bile duct and the hepatic artery. The right graft retains the portal trunk, the common bile duct and the right branch of the hepatic artery. This procedure was used for emergency grafting of two patients with fulminant hepatitis when only one donor was available. Both recipients recovered from coma and regained normal liver function. However, both died from causes not specifically related to the operative technique, one from multiple organ failure on the 20th day and the other from diffuse cytomegalovirus infection on the 45th day.