BackgroundPerioperative bleeding and transfusion are important causes of morbidity and mortality in patients undergoing liver transplantation. The aim of this study is to assess whether viscoelastic tests-guided therapy with the use of synthetic factor concentrates impact transfusion rates of hemocomponents in adult patients undergoing liver transplantation.MethodsThis is an interventional before-after comparative study. Patients undergoing liver transplantation before the implementation of a protocol using thromboelastometry and synthetic factor concentrates were compared to patients after the implementation. Primary outcome was transfusion of any hemocomponents. Secondary outcomes included: transfusion of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate or platelets, clinical complications, length of stay and in-hospital mortality.ResultsA total of 183 patients were included in the control and 54 in the intervention phase. After propensity score matching, the proportion of patients receiving any transfusion of hemocomponents was lower in the intervention phase (37.0 vs 58.4%; OR, 0.42; 95% CI, 0.20–0.87; p = 0.019). Patients in the intervention phase received less RBC (30.2 vs 52.5%; OR, 0.21; 95% CI, 0.08–0.56; p = 0.002) and FFP (5.7 vs 27.3%; OR, 0.11; 95% CI, 0.03–0.43; p = 0.002). There was no difference regarding transfusion of cryoprecipitate and platelets, complications related to the procedure, hospital length of stay and mortality.ConclusionsUse of a viscoelastic test-guided transfusion algorithm with the use of synthetic factor concentrates reduces the transfusion rates of allogenic blood in patients submitted to liver transplantation.Trial registrationThis trial was registered retrospectively on November 15th, 2018 – clinicaltrials.gov – Identifier: NCT03756948.Electronic supplementary materialThe online version of this article (10.1186/s12871-018-0664-8) contains supplementary material, which is available to authorized users.
Perioperative monitoring of coagulation is vital to assess bleeding risks, diagnose deficiencies associated with hemorrhage, and guide hemostatic therapy in major surgical procedures, such as liver transplantation. Routine static tests demand long turnaround time and do not assess platelet function; they are determined on plasma at a standard temperature of 37°C; hence these tests are ill-suited for intraoperative use. In contrast, methods which evaluate the viscoelastic properties of whole blood, such as thromboelastogram and rotational thromboelastometry, provide rapid qualitative coagulation assessment and appropriate guidance for transfusion therapy. These are promising tools for the assessment and treatment of hyper- and hypocoagulable states associated with bleeding in liver transplantation. When combined with traditional tests and objective assessment of the surgical field, this information provides ideal guidance for transfusion strategies, with potential improvement of patient outcomes.
IntroductionRobotic-assisted surgery (RAS) has emerged as an alternative minimally invasive surgical option. Despite its growing applicability, the frequent need for pneumoperitoneum and Trendelenburg position could significantly affect respiratory mechanics during RAS. AVATaR is an international multicenter observational study aiming to assess the incidence of postoperative pulmonary complications (PPC), to characterise current practices of mechanical ventilation (MV) and to evaluate a possible association between ventilatory parameters and PPC in patients undergoing RAS.Methods and analysisAVATaR is an observational study of surgical patients undergoing MV for general anaesthesia for RAS. The primary outcome is the incidence of PPC during the first five postoperative days. Secondary outcomes include practice of MV, effect of surgical positioning on MV, effect of MV on clinical outcome and intraoperative complications.Ethics and disseminationThis study was approved by the Institutional Review Board of the Hospital Israelita Albert Einstein. The study results will be published in peer-reviewed journals and disseminated at international conferences.Trial registration numberNCT02989415; Pre-results.
Hydrothorax is a frequent finding in patients with endstage liver disease. During the hepatectomy phase of liver transplantation, it is often needed to evacuate large pleural effusions. The acute expansion of the collapsed lung can cause reexpansion pulmonary edema with variable clinical significance. However, this complication has rarely been reported after liver transplantation. In conclusion, we report on an overwhelming reexpansion pulmonary edema during a liver transplantation that rapidly led to the patient's demise and speculate if this condition has not been under recognized in the transplantation setting. N oncardiogenic acute pulmonary edema (PE) may complicate the perioperative course of patients undergoing liver transplantation (LT). 1,2 Using radiography and partial pressure of oxygen, arterial/fraction of inspired oxygen ratio Ͻ300 as diagnostic criteria, Aduen et al. found PE in 52% of the patients undergoing LT. 3 Immediate PE occurred in 25% of the patients, 9% had late PE (developing de novo in the first 16 to 24 hours), and 18% had persistent PE (developing immediately and persisting for at least 16 hours). Immediate PE had little clinical consequence, resolving within 24 hours, but persistent permeability-type PE portended a worse outcome. This diffuse edema has been attributed to multiple etiologies: fluid overload, transfusion-related acute lung injury (TRALI), acute respiratory distress syndrome (ARDS), and PE associated with fulminant hepatic failure. 2 The underlying pathophysiologic disturbances involve either an imbalance in the transcapillary hydrostatic forces (hydrostatic-type PE) or a disruption of the permeability barrier (permeability-type PE).A rare cause of noncardiogenic PE is a form of a nondiffuse type of pulmonary endothelial injury that occurs following rapid air expansion of a collapsed lung, the so-called reexpansion pulmonary edema (REPE). 4 In the LT setting, large pleural effusions are a common finding and are frequently evacuated during the procedure. It is well recognized that the rapid evacuation of large volumes of air or fluid from the pleural space can cause REPE with variable clinical significance. However, this complication after LT was only reported by Jabber et al., who described a single case with a benign course. 5 Herein, we report an overwhelming perioperative REPE during a LT that rapidly led to the patient's demise and speculate if this condition has not been underrecognized in the LT setting. Case ReportA 47-year-old male farmer with Child-Turcotte-Pugh C cirrhosis secondary to recurrent hepatitis B underwent hepatic retransplantation. Preoperative cardiovascular and respiratory work-up showed only moderate right pleural effusion. After induction of the anesthesia, the ventilator was set to conventional parameters (fraction of inspired oxygen: 40%; positive end-expiratory pressure, 5 cm H 2 O) and 2 large-bore central catheters were placed into the right internal jugular vein. Arterial blood gases and hemodynamic measurements were within the normal ra...
Data collection for clinical research can be difficult, and electronic health record systems can facilitate this process. The aim of this study was to describe and evaluate the secondary use of electronic health records in data collection for an observational clinical study. We used Cerner Millennium®, an electronic health record software, following these steps: (1) data crossing between the study’s case report forms and the electronic health record; (2) development of a manual collection method for data not recorded in Cerner Millennium®; (3) development of a study interface for automatic data collection in the electronic health records; (4) employee training; (5) data quality assessment; and (6) filling out the electronic case report form at the end of the study. Three case report forms were consolidated into the electronic case report form at the end of the study. Researchers performed daily qualitative and quantitative analyses of the data. Data were collected from 94 patients. In the first case report form, 76.5% of variables were obtained electronically, in the second, 95.5%, and in the third, 100%. The daily quality assessment of the whole process showed complete and correct data, widespread employee compliance and minimal interference in their practice. The secondary use of electronic health records is safe and effective, reduces manual labor, and provides data reliability. Anesthetic care and data collection may be done by the same professional.
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