Correction of coagulation defects with plasma transfusion did not decrease the need for intraoperative red blood cells (RBC) transfusions during liver transplantations. On the contrary, it led to a hypervolemic state that resulted in an increase of shed blood. As well, plasma transfusion has been associated with a decreased one-year survival rate. The aim of the present prospective survey was to evaluate whether anesthesiologists could reduce intraoperative RBC transfusions during liver transplantations by changing their anesthesia practice, more specifically by maintaining a low central venous pressure (CVP), through restriction of volume replacement, elimination of all plasma transfusion and by using intraoperative phlebotomy during the transplantation. One hundred consecutive liver transplantations were prospectively studied during a two-year period and were compared to a retrospective series (1998)(1999)(2000)(2001)(2002). A low CVP was maintained in all patients prior the anhepatic phase. Coagulation disorders were not corrected preoperatively, intraoperatively, or post-operatively unless uncontrollable bleeding. Phlebotomy and Cell Saver (CS) were used following pre-established criteria. Independent variables were analyzed in a univariate and multivariate fashion. The mean number of intraoperative RBC units transfused was 0.4 Ϯ 0.8. No plasma, platelets, albumin, or cryoprecipitate were transfused. Seventy-nine percent of the patients received no blood products during their liver transplantation. The average final hemoglobin value was 85.9 Ϯ 17.8 g/L. In 57 patients (58.2%), intraoperative phlebotomy and CS were used either together or separately. The one-year year survival rate was 89.1%. Logistic regression showed that avoidance of plasma transfusion, starting hemoglobin value and phlebotomy were significantly linked to liver transplantation without RBC transfusion. In conclusion, the avoidance of plasma transfusion and maintenance of a low CVP prior to the anhepatic phase were associated with a decrease in RBC transfusions during liver transplantations. Previous reports indicating that it is neither useful nor necessary to correct coagulation defects with plasma transfusion prior to liver transplantation are further corroborated by this prospective survey. We believe that this work also supports the practice of lowering CVP with phlebotomy in order to reduce blood loss, during liver dissection, without any deleterious effect. Liver
Although we cannot demonstrate causality, our analysis shows that our one-year survival rate following liver transplantation decreased significantly with the intraoperative transfusion of any amount of plasma or more than four units of RBC.
Background We have always been searching for the ideal local anesthetic for outpatient spinal anesthesia. Lidocaine has been associated with a high incidence of transient neurological symptoms, and bupivacaine produces sensory and motor blocks of long duration. Preservative-free 2-chloroprocaine (2-CP) seems to be a promising alternative, being a short-acting agent of increasing popularity in recent years. This study was designed to compare 2-CP with bupivacaine for spinal anesthesia in an elective ambulatory setting. Methods A total of 106 patients were enrolled in this randomized double-blind study. Spinal anesthesia was achieved with 0.75% hyperbaric bupivacaine 7.5 mg (n = 53) or 2% preservative-free 2-CP 40 mg (n = 53). The primary endpoint for the study was the time until reaching eligibility for discharge. Secondary outcomes included the duration of the sensory and motor blocks, the length of stay in the postanesthesia care unit, the time until ambulation, and the time until micturition. Results The average time to discharge readiness was 277 min in the 2-CP group and 353 min in the bupivacaine group, a difference of 76 min (95% confidence interval [CI]: 40 to 112 min; P \ 0.001). The average time for complete regression of the sensory block was 146 min in the 2-CP group and 329 min in the bupivacaine group, a difference of 185 min (95% CI: 159 to 212 min; P \ 0.001). Times to ambulation and micturition were also significantly lower in the 2-CP group. Conclusion Spinal 2-chloroprocaine provides adequate duration and depth of surgical anesthesia for short procedures with the advantages of faster block resolution and earlier hospital discharge compared with spinal bupivacaine. (ClinicalTrials.gov number, NCT00845962). RésuméContexte Nous sommes depuis toujours a`la recherche de l'anesthe´sique local ide´al pour l'anesthe´sie rachidienne ambulatoire. La lidocaı¨ne a e´te´associe´e à une incidence e´leve´e de symptômes neurologiques temporaires, et la bupivacaı¨ne produit des blocs sensitifs et moteurs de longue dure´e. La 2-chloroprocaı¨ne (2-CP) sans agent de conservation semble eˆtre une alternative prometteuse, e´tant donne´qu'il s'agit d'un agent a`courte action qui gagne en popularite´depuis quelques anne´es. Cette e´tude a e´te´conçue afin de comparer la 2-CP a`la bupivacaı¨ne pour la rachianesthe´sie dans un contexte ambulatoire et non urgent.
Oesophageal, rectal, axillary, tympanic and pulmonary artery temperatures during cardiac surgery Purpose: The gradient between temperatures measured at different body sites is not constant; one factor which will change this gradient is rapid changes in body temperature. Measurement of this gradient was done in patients undergoing rapid changes in body temperature to establish the best site to measure temperature and to compare two brands of commercial tympanic thermometers. Method: Atotal of 228 sets of temperatures were measured from probes in the oesophagus, rectum, and axilla and from two brands of tympanic thermometer and compared with pulmonary artery (PA) temperature in 18 adults during cardiac surgery. Results: Measurements from the oesophageal site was closest to PA readings (mean difference 0.0 • 0.5~ compared with IVAC tympanic thermometer (mean difference -0,3 _ 0.5~ Genius tympanic thermometer (mean difference -0.4 • 0.5~ axillary (mean difference 0.2 • 1.0~ and rectal (mean difference -0.4 • 1.0~ readings, When data during cooling were analysed separately, all sites had similar gradients from PA except for rectal, which was larger. On rewarming, oesophageal readings were closest to PA readings; tympanic readings were doser to PA than were rectal or axillary readings. Readings from the two brands of tympanic thermometer were equivalent. Conclusion: Oesophageal temperature is more accurate and will reflect rapid changes in body temperature better than tympanic, axillary, or rectal temperature. When oesophageal temperature cannot be measured, tympanic temperature done by a trained operator should become the reading of choice.Objectif : Le gradient entre les mesures de temp&ature r~alis~es ~. diff&ents endroits du corps n'est pas constant; les changements rapides de la temp&ature corporelle repr&entent un des facteurs moditiant ce gradient. Ce demier a ~t~ mesur~ chez des patients subissant des changements rapides de la temperature corporelle dans le but d'identitier le meilleur endroit o~ mesurer la temperature et dans le but de comparer deux marques de thermom~tre tympanique sur le march~, M&hode : Un total de 228 groupes de mesures de la temperature ont ~t~ obtenues ~ partir des sites oesophagien, rectal, axillaire et tympanique (deux marques de thermom&re) et ont ~t~ compares aux mesures r6alis&s dans I'art&e pulmonaire chez 18 adultes subissant une chirurgie cardiaque. R~ultats : Les mesures oesophagiennes 6taient les plus proches de celles de I'art&e pulmonaire (difference moyenne (0,0 _ 0,5~ comparativement aux mesures tympaniques par thermom~.tre IVAC( -0,3 _ 0,5~ et Genius (-0,4 _ 0,5~ aux mesures axillaires (0,2 -I~ et aux mesures rectales (-0,4 • I ~ Lorsque les mesures durant le refroidissement ~taient analys~es s~par~ment, tousles sites d~montraient des gradients analogues par rapport ~ I'art&e pulmonaire, sauf le rectum qui d~montrait un gradient plus considerable. Lots du r&hauffement, les mesures oesophagiennes &aient plus proches de celles de I'art&e pulmonaire, suivies des mesures tym...
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