27 de junho de 2013

Artigo recomendado: Preparation of the patient for liver transplantation

Eduardo F Viñuela, Darius F Mirza

Indian Journal of Transplantation 2011 July–September (Supplement)
Volume 5, Number 3; pp. 120–125 Review Article


Liver transplantation (LT) is an established life-saving treatment for patients with end-stage liver disease (ESLD), and as greater expertise and better care of these patients is available, the number of patients eligible for LT will continue to increase. Unfortunately, this ever-growing demand is not met by a comparable augmentation in the rate of donation. Therefore, it is common for most candidates to spend considerable time in the waiting list. During this period, patients are at risk of developing complications from ESLD that may negatively affect their expected postoperative outcome.

In addition, progression of their liver disease or other co-morbidities may result in them no longer being healthy enough to undergo LT. This paper focuses on the strategies and recommendations for the prevention, timely detection and management of complications diagnosed either, at the time of initial evaluation, or while the patient is waiting for LT in order to optimize the perioperative and long-term outcomes.

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24 de junho de 2013

Artigo recomendado: Liver Transplantation Due to Fulminant Hepatic Failure

V. Gómez Cabeza de Vaca, C. Bernal Bellido, J.N. Álamo Martínez, G. Suárez Artacho, L.M. Marín Gómez, J. Serrano Díaz-Canedo, F.J. Padillo Ruiz, and M.A. Gómez Bravo

Transplantation Proceedings, 44, 2076–2077 (2012) by Elsevier Inc. All rights reserved.

Objectives: To analyze the epidemiology, causes, complications, and mortality of liver transplants following fulminant hepatic failure over the last 16 years.

Materials and methods: We completed a descriptive analysis of 21 patients with fulminant hepatic failure and a liver transplant. In almost half of the cases, the origin of liver failure was unknown.

Results: The mean age was 36 years; the study group was 47.61% female (n = 10) and 52.39% male (n = 11). The most common early complication was transplant rejection, which occurred in 33.3% of all patients (n = 7) and was confirmed by liver biopsy; the most frequent long-term complication was autoimmune hepatitis. Two retransplantations were necessary. The total mortality rate was 38.1% (n = 8) with late mortality in three patients (14.3%).

Conclusions: Orthotopic liver transplantation as a treatment for fulminant hepatitis has a higher mortality rate than orthotopic liver transplantation due to other causes. It does, however, enable the survival of 62% of the patients who otherwise would have died due to liver failure. The etiology of most of the cases was unknown. We should point out the high incidence rates for transplant rejection and late autoimmune hepatitis, in addition to the possibility of hemorrhagic colonic diseases that may be associated with the condition causing liver failure. Multidisciplinary control over the patient is useful for deciding at which time a liver transplant would become the only treatment option.

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14 de junho de 2013

Artigo recomendado: Live related Liver Transplantation, Intra operative Anaesthetic Management - Our Initial Experience

Dr. Vasanth Rao, Dr. Mohd Rehman, Dr. L. Talwalkar, Dr. S. Anand, Dr. C. Ann, Dr. Vasudev, Dr. Steve Dunn, Dr. Philip Thomas, Dr. Ashley D’cruz

Indian J. Anaesth. 2004; 48 (3) : 208-211

Live related liver transplatation is being accepted as a new mode of treatment for children with endstage liver disease with a dedicated team of cliniciens it is possible to meet the challenge of anaesthesia and surgery of LRLT succesfully with limited resources. The same is presented here below.

Basically the anaesthetic management of live related liver transplantation (LRLT) is similar to orthotopic liver transplantation and management of such cases were reported more than 2 decades ago. In developing nation like India it is challenging for an anaesthesiologist to do LRLT without latest equipment as generally transplant set up is equipped with cardiac, respiratory monitors, veno-venous bypass machine cell saver devices, rapid infusion devices and thromboelastograph. Despite using few of these monitors it is still possible to do LRLT, with dedication, commitment and concentration over long operative hours. In this article we would like to describe our initial experience and one of the few paediatric cases done in India.

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11 de junho de 2013

Artigo recomendado: Intraoperative Resource Utilization in Anesthesia for Liver Transplantation in the United States: A Survey

Roman Schumann

Anesth Analg 2003;97:21–8

Among the intraoperative resources expended for liver transplantation, laboratory tests, personnel, high-flow infusion devices, high-tech monitoring equipment, and veno-venous bypass vary from institution to institution. Although of obvious interest to the anesthesia liver transplantation community and others, little is known regarding current utilization of these resources on a national level. To determine the resource utilization among liver transplantation centers in the United States, we conducted a national survey between April and July 2002. Results were stratified according to pediatric versus adult recipient populations and transplantation case volume. Of 99 centers that received the survey by mail, 66 (66.6%) responded. Pediatric liver transplantation programs were distinctly different in personnel, equipment, monitoring, and veno-venous bypass utilizationwhencompared with adult or mixedage programs. Among laboratory studies, statistically significant trends emerged for fewer intraoperative determinations of the activated clotting time, magnesium, and phosphate with increasing transplantation volume.
The results describe national practice patterns and may be useful for programs to compare their approaches and develop clinical pathways. There is wide variation of resource use between centers. The survey results do not consistently correlate with the few recommendations found in the current literature.

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7 de junho de 2013

Artigo recomendado: Intraoperative management of liver transplant patients

Linda L. Liua, Claus U. Niemanna

L.L. Liu, C.U. Niemann / Transplantation Reviews 25 (2011) 124–129


Liver transplantation for end-stage liver disease results in excellent outcomes. Patient and graft outcome is closely monitored on a national level, and 1-year survival is between 80% and 95%. Liver transplantation relies on a multidisciplinary approach, with close involvement of anesthesiologists and intensivists. However, intraoperative care of these patients remains inconsistent and is highly institution dependent.

This brief-review article will focus on controversial topics of intraoperative care. Existing evidence on intraoperative monitoring, intraoperative fluid and transfusion management, electrolyte and glucose management, postoperative patient disposition, and, lastly, anesthesia team management will be reviewed.

© 2011 Elsevier Inc. All rights reserved.

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4 de junho de 2013

Artigo recomendado: Anesthetic considerations during liver surgery

Imre Redai, Jean Emond, Tricia Brentjens

I. Redai et al / Surg Clin North Am 84 (2004) 401–411

Recent advances in surgical and anesthetic management have reduced the operative risk of major hepatectomies significantly. Although these advances have been multifactorial, anesthetic approaches derived from liver transplantation have had a major impact in our own practice and given us greater capacity to perform complex resections safely. We have been liberal in the use of vascular isolation techniques to prevent hemorrhage in our approach to liver surgery, a modification that mandates a high level of anesthetic expertise to manage complex liver cases [1].

Understanding the underlying pathological conditions of liver disease and the physiology of vascular exclusion and surgical resection has significantly contributed to goal-oriented anesthetic management. The recognition of the importance of expert anesthetic management for liver surgery has led to the formation of anesthesiology teams dedicated to liver surgery and transplantation in most major institutions.

Preoperative considerations
Our experience with hepatectomy over nearly 2 decades has spanned a broad range of clinical scenarios, ranging from the healthy living donor to the patient with advanced cirrhosis undergoing local excision of a malignancy. The preoperative assessment is tailored to accommodate the clinical needs of the patient, estimating the need for invasive monitoring based on the extent of resection and the general health of the patient. Otherwise healthy individuals presenting for even extensive liver surgery need no additional work-up other than routine preoperative laboratories, which include a complete blood count, serum chemistries, and plasma coagulation studies. Increasingly, patients with significant comorbidities are scheduled for major liver resections. Assessing the functional status of these patients is often a significant challenge, as very few tests are available to assess with adequate predictive power the hemodynamic, respiratory, and hepatic reserve in this population...

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