Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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In this study, we compared continuous cardiac output (CO) obtained from the femoral arterial pressure by simulation of an aortic input impedance model [model-simulated cardiac output (MCO)] to thermodilution cardiac output (TDCO) determined by bolus injection during liver transplantation. Both variables were measured in 39 adult patients (13 females) every 10th minute during liver transplant surgery. Paired measurements were compared during the 4 phases of surgery-dissection, anhepatic phase, early reperfusion (the first 15 minutes after reperfusion), and late reperfusion (15-60 minutes after reperfusion)-without the detection of any significant difference between the 2 estimates of CO. ⋯ After calibration of the first determined MCO by the simultaneously determined TDCO, the bias was 0.1 +/- 1.5 L/minute, with 57% (n = 744) of the comparisons being less than 1 L/minute and 35% (n = 453) being less than 0.5 L/minute; this was independent of the level of CO, and the mutual correlation coefficient was 0.812 (P < 0.001). This study indicates that during liver transplantation surgery, MCO reflects TDCO throughout the operation. Thus, for CO, this less invasive method appears to provide a reliable uninterrupted measurement during orthotopic liver transplantation.
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Early detection of vascular complications following liver surgery is crucial. In the present study, intrahepatic microdialysis was used for continuous monitoring of porcine liver metabolism during occlusion of either the portal vein or the hepatic artery. Our aim was to assess whether microdialysis can be used to detect impaired vascular inflow by metabolic changes in the liver. ⋯ Surprisingly, portal occlusion resulted in no major metabolic changes. In conclusion, the microdialysis technique can detect and monitor arterial vascular complications of liver surgery, whereas potential metabolic changes in the liver induced by portal occlusion were not seen in the current study. Microdialysis may thus be suitable for use in liver surgery to monitor intrahepatic metabolic changes.
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Acute kidney injury (AKI) is common in liver failure prior to orthotopic liver transplantation (OLT) and may complicate the intraoperative course. We describe the logistics of intraoperative continuous renal replacement therapy (CRRT) during OLT and the associated clinical outcomes. We performed a retrospective review of adult patients (age > 18 years) receiving intraoperative CRRT during OLT at the University of Alberta Hospital between January 1, 1996 and December 31, 2005. ⋯ In conclusion, our data suggest that intraoperative CRRT during OLT is achievable and safe. Intraoperative CRRT may be a valuable adjuvant therapy for those with preoperative AKI. Additional investigations are warranted.
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Because of organ shortage and a constant imbalance between available organs and candidates for liver transplantation, expanded criteria donors are needed. Experience shows that there are wide variations in the definitions, selection criteria, and use of expanded criteria donors according to different geographic areas and different centers. Overall, selection criteria for donors have tended to be relaxed in recent years. ⋯ It is emphasized that donor quality represents a continuum of risk rather than "good or bad." A distinction is made between donor factors that generate increased risk of graft failure and factors independent of graft function, such as transmissible infectious disease or donor-derived malignancy, that may preclude a good outcome. Updated data concerning the risks associated with different donor variables in different recipient populations are given. Recommendations on how to safely expand donor selection criteria are proposed.
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Recombinant human activated protein C (rhAPC) has been approved for use in patients with severe sepsis at high risk of death. Because of the high risk of bleeding, liver transplantation (LT) patients have been excluded from the randomized control trials that evaluated efficacy and safety of rhAPC and, thus, few data are available on the use of this drug in LT patients with severe sepsis. ⋯ During rhAPC infusion, 4 patients received fresh frozen plasma and/or platelet concentrates because of thrombocytopenia and severe hemostasis dysfunction. No major bleeding occurred and only 1 patient presented with minor bleeding events.