BackgroundProlonged mechanical ventilation after liver transplantation has been associated with deleterious clinical outcomes, so early tracheal extubation posttransplant is now increasing. However, there is no universal clinical criterion for predicting early extubation in living-donor liver transplantation (LDLT). We investigated specific predictors of early extubation after LDLT.MethodsPerioperative data of adult patients undergoing LDLT were reviewed. "Early" extubation was defined as tracheal extubation in the operating room or intensive care unit (ICU) within 1 h posttransplant, and we divided patients into early extubation (EX) and non-EX groups. Potentially significant (P < 0.10) perioperative variables from univariate analyses were entered into multivariate logistic regression analyses. Individual cut-offs of the predictors were calculated by area under the receiver operating characteristic curve (AUC) analysis.ResultsOf 107 patients, 66 (61.7%) were extubated early after LDLT. Patients in the EX group showed shorter stays in the hospital and ICU and lower incidences of reoperation, infection, and vascular thrombosis. Preoperatively, model for end-stage liver disease score, lung disease, hepatic encephalopathy, ascites, and intraoperatively, surgical time, transfusion of packed red blood cell (PRBC), urine output, vasopressors, and last measured serum lactate were associated with early extubation (P < 0.05). After multivariate analysis, only PRBC transfusion of ≤ 7.0 units and last serum lactate of ≤ 8.2 mmol/L were selected as predictors of early extubation after LDLT (AUC 0.865).ConclusionsIntraoperative serum lactate and blood transfusion were predictors of posttransplant early extubation. Aggressive efforts to ameliorate intraoperative circulatory issues would facilitate successful early extubation after LDLT.

Objectives: Magnesium has protective effects in ischaemiareperfusion injury, and is involved in immunomodulation. We investigated the effects of magnesium pretreatment on the secretion of T helper (Th) cytokines and on the severity of post-reperfusion syndrome (PRS) in patients undergoing living donor liver transplantation (LDLT). Methods: forty patients were allocated to two groups of 20 (magnesium and saline groups). Blood samples for cytokine analysis were collected before infusion of the study solution at the end of anhepatic phase (time point 1), as well as five min and 30 min after allograft reperfusion (time points 2 and 3, respectively). Levels of cytokines were quantified using a sandwich enzyme immunoassay test kit. Results: The duration of PRS was shorter in the magnesium group (p = 0.038). The level of interferon (IFN)-␥ released from Th1 was lower in the magnesium group at time point 3 (p = 0.009). Of the cytokines released from Th2 cells, interleukin (IL)-6 was present in higher concentrations in the magnesium group at time points 2 and 3 (p<0.05). The concentrations of IL-4 and IL-10, which were secreted from Th2 cells, were also higher in the magnesium group at time point 3 (p<0.05). The IFN-␥ /IL-6, IFN-␥ /IL-4 and IFN-␥ /IL-10 ratios were lower in the magnesium group after allograft reperfusion. Conclusions: Magnesium pretreatment attenuated PRS and reinforced Th2 cell activity, shifting the Th1-to-Th2 cytokine balance towards Th2 in patients undergoing LDLT.

Background: Sacroiliac intraarticular injection by the traditional technique can be challenging to perform when the joint is covered with osteophytes or is extremely narrow. Objective: To examine whether there is enough space for the needle to be advanced from the L5-S1 interspinous space to the upper one-third sacroiliac joint (SIJ) by magnetic resonance image (MRI) analysis as an alternative to fluoroscopically guided SIJ injection with the lower one-third joint technique, and to determine the feasibility of this novel technique in clinical practice. Study Design: MRI analysis and observational study. Setting: An interventional pain management practice at a university hospital. Methods: We analyzed 200 axial T2-weighted MRIs between the L5 and S1 vertebrae of 100 consecutive patients. The following measurements were obtained on both sides: 1) the thickness of fat in the midline; 2) the distance between the midline (Point C) and the junction (Point A) of the skin and the imaginary line that connects the SIJ and the most medial cortex of the ilium; 3) the distance between the midline (Point C) and the junction (Point B) of the skin and the imaginary line that connects the SIJ and the L5 spinous process; 4) the distance between the SIJ and midline (Point C) on the skin, or between the SIJ and the midpoint (Point C’) of the line from Point A to Point B; and 5) the angle between the sagittal line and the imaginary line that connects the SIJ and the midline on the skin. The upper one-third joint technique was performed to establish the feasibility of the alternative technique in 20 patients who had unsuccessful sacroiliac intraarticular injections using the lower one-third joint technique. Results: The mean distances from the midline to Point A and to Point B were 21.9 ± 13.7 mm and 27.8 ± 13.6 mm, respectively. The mean distance between the SIJ and Point C (or Point C’) was 81.0 ± 13.3 mm. The angle between the sagittal line and the imaginary line that connects the SIJ and the midline on the skin was 42.8 ± 5.1°. The success rate of sacroiliac intraarticular injections with the upper one-third joint technique was 90% (18/20). Limitations: This was an observational study and lacked a control group. Conclusions: Sacroiliac intraarticular injections with the upper one-third joint technique are advisable when it is hard to perform them with the lower one-third joint technique. Key words: Buttock pain, fluoroscopy, low back pain, sacroiliac joint, sacroiliac joint pain