Postoperative atrial fibrillation (POAF) is common after major surgeries and is associated with increased morbidity and mortality. POAF after liver transplantation (LT) has not been reported. This study was undertaken to investigate the incidence, impact, and risk factors of POAF in LT patients. After IRB approval, LT between January 2006 and August 2013 at our center were retrospectively reviewed. POAF that occurred within 30 days after LT was included. Patients with and without POAF were compared and independent risk factors were identified by logistic regression. Of 1387 adults LT patients, 102 (7.4%) developed POAF during the study period. POAF was associated with significantly increased mortality, graft failure, acute kidney injury and prolonged hospital stay. Independent risk factors included age, body weight, MELD score, presence of previous history of AF, the vasopressors use prior to LT and pulmonary artery diastolic pressure at the end of LT surgery (odds ratios 2.0-7.2, all p < 0.05). A risk index of POAF was developed and patients with the high-risk index had more than 60% chance of developing POAF. These findings may be used to stratify patients and to guide prophylaxis for POAF in the posttransplant period.
Donation after cardiac death (DCD) is an important source for expanding the donor pool for liver transplantation (LT).Although the long-term outcomes of LT using DCD grafts have been extensively studied, perioperative complications related to DCD grafts are rarely reported. The aim of this study was to determine whether DCD grafts were associated with a higher incidence of postreperfusion complications and worse outcomes in adult LT patients. After institutional review board approval, the medical records of all adult patients who underwent LT at our medical center between 2004 and 2011 were reviewed. Postreperfusion complications and posttransplant outcomes were compared between patients receiving DCD grafts and patients receiving donation after brain death (DBD) grafts. In all, 74 patients received DCD grafts during the study period, and 1369 patients received DBD grafts. An initial comparison showed that many preoperative, prereperfusion, and donor variables in the DCD group differed significantly from those in the DBD group. Propensity matching was chosen so that adjustments could be made for the differences. A postmatching analysis showed that the preoperative, prereperfusion, and donor variables no longer differed between the 2 groups. The postreperfusion requirements for blood products and vasopressors, the posttransplant ventilation times, the incidence of posttransplant acute renal injury, and the 30-day and 1-year patient and graft survival rates were comparable between the 2 groups. However, patients receiving DCD grafts experienced significantly higher rates of hyperkalemia (33.8% versus 18.9%, P < 0.05) and postreperfusion syndrome (PRS; 25.7% versus 12.3%, P < 0.05). In conclusion, after adjustments for preoperative and prereperfusion risks via propensity matching, DCD grafts remained a risk factor for postreperfusion hyperkalemia and PRS. A prophylactic regimen aimed at decreasing postreperfusion hyperkalemia and PRS is recommended for the management of LT using DCD grafts. Liver The demand for organs for liver transplantation (LT) continues to exceed the supply. The discrepancy between the number of available organs and the number of patients waiting for transplantation remains significant. 1 To address this urgent shortage and the rising wait-list mortality rate, the expansion of the donor pool through the use of donation after cardiac death (DCD) grafts has been promoted. 2 Although donation after brain death (DBD) remains the predominant source of deceased donor grafts, the use of DCD grafts in LT is being increasingly accepted worldwide. Now LT using DCD grafts accounts for approximately 5% of all Abbreviations: ARI, acute renal injury; BMI, body mass index; CIT, cold ischemia time; DBD, donation after brain death; DCD, donation after cardiac death; DWIT, donor warm ischemia time; FFP, fresh frozen plasma; GWIT, graft warm ischemia time; ICU, intensive care unit; LT, liver transplantation; MELD, Model for End-Stage Liver Disease; PRS, postreperfusion syndrome; RBC, red blood cell; UCLA, Univer...
Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30 days after LT between 2006 and 2013 were studied. Of 502 patients, 203 (40.4%) met the diagnostic criteria (cTn I ≥0.1 ng/mL) of myocardial injury. The majority of myocardial injury occurred within the first three postoperative days and presented without clinical signs or symptoms of myocardial infarction. Thirty-day mortality in patients with myocardial injury was 11.4%, significantly higher compared with that in patients without myocardial injury (3.4%, P<.01). Cox analysis indicated the peak cTn was significantly associated with 30-day mortality. Multivariable logistic analysis identified three independent risk factors: requirement of ventilation before transplant (odds ratios (OR) 1.6, P=.006), RBC≥15 units (OR 1.7, P=.006), and the presence of PRS (OR 2.0, P=.028). We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted.
Pretransplant neurological complications were prevalent, and severe posttransplant BI occurred at a rate of 7.8% and was significantly associated with severe pretransplant cerebral edema and postoperative international normalized ratio. Our findings support the use of pretransplant computed tomography. If severe pretransplant cerebral edema is confirmed, efforts should be made to aggressively control intracranial pressure and select a proper donor to minimize the risk of severe posttransplant BI and futile transplantation.
Background Local anaesthetic infiltration is widely used to reduce pain after laparoscopic cholecystectomy (LC). This trial evaluated the effect of depth of local anaesthetic infiltration on postoperative pain reduction after LC. Methods Patients undergoing elective LC between March 2018 and February 2019 were randomized into no infiltration, subcutaneous infiltration, and rectus sheath infiltration using bupivacaine. The primary outcome was 24-h postoperative cumulative morphine use, and the secondary outcomes were mean 24-h Numerical Rating Scale (NRS) for pain, and nausea, and vomiting. Subgroups were compared and multivariable analyses were performed. Results Out of 170 eligible patients, 162 were selected and 150 patients were analysed: 48 in the no-infiltration group, 50 in the subcutaneous infiltration group, and 52 in the rectus sheath infiltration group. The groups had similar clinical features, although mean BMI was higher in the subcutaneous infiltration group (P = 0.001). The 24-h cumulative morphine use in the rectus sheath infiltration group was significantly lower than in the no-infiltration group (P = 0.043), but no difference was observed between the subcutaneous infiltration and no-infiltration groups (P = 0.999). One hour after surgery, the rectus sheath infiltration group had a significantly lower NRS score than the no-infiltration and subcutaneous infiltration groups respectively (P = 0.006 and P = 0.031); however, the score did not differ among the three groups at any of the time points from 2 h after the surgery. The incidence of nausea or vomiting was comparable among the three groups. Multivariable analysis documented that a lower dose of morphine use was associated with rectus sheath infiltration (P = 0.004) and diabetes (P = 0.001); whereas, increased morphine use was associate with age (P = 0.040) and a longer duration of surgery (P = 0.007). Conclusions Local anaesthetic infiltration into the rectus sheath reduced postoperative cumulative morphine use and the immediate NRS score in patients undergoing LC; however, the pain scores were comparable 2 h after surgery. Registration number TCTR20201103002 (http://www.thaiclinicaltrials.org).
Background: Pediatric liver transplantation (LT) has been accepted as a definitive treatment for end-stage liver disease. Pleural effusion is a common pulmonary complication following LT in children. The objectives of the study were to identify prevalence of post-LT pleural effusion, risk factors, and the impact on patients' outcomes. Methods: A retrospective study was conducted in 107 pediatric patients who underwent LT at our center between March 2001 and June 2018. They were categorized into pleural effusion and non-pleural effusion groups. Preoperative and perioperative data, intraoperative findings, liver graft characteristics, and perioperative outcomes were compared between the two groups. Results: Post-LT pleural effusion occurred in 64 (59.8%) patients. There were more patients with PELD score ≥ 18 in the pleural effusion group (68.8 vs 48.8%, P=0.039). Other preoperative and perioperative data were not significantly different. The pleural effusion group had a higher rate of reoperation than non-pleural effusion group (55.6 vs 30.9%, P=0.013). Median oxygen dependence time, length of ICU and hospital stay were significantly longer in the pleural effusion group (18.5 vs 7.0, 10 vs 7 and 48 vs 34 days, respectively, P <0.05). However, mortality was not significantly different. Among the patients with pleural effusion, median time to extubation, oxygen dependence time, length of ICU and hospital stay were significantly longer in those who required therapeutic interventions than those without interventions (12 vs 3, 31 vs 10, 17 vs 8, and 60 vs 43 days, respectively, P <0.05). Conclusion: Pleural effusion following pediatric LT is common and its potential risk factor is PELD score at LT ≥ 18. Post-LT pleural effusion is associated with prolonged oxygen dependence time, ICU stay and hospital stay, particularly those who required therapeutic interventions.
Background Intraoperative hyperglycemia has been associated with multiple postoperative complications such as surgical site infection, myocardial infarction, stroke, and death. These complications are not confined to only diabetic patients. However, the incidence of intraoperative hyperglycemia in non-diabetic patients has not been fully elucidated. Additionally, these patients’ risk factors were not well established in previous studies. Methods Four hundred forty non-diabetic patients who underwent intermediate- to high-risk surgery were included in the study. We prospectively measured the capillary blood glucose level in all patients during surgery. The incidence of intraoperative hyperglycemia was defined as at least one episode of blood glucose level of more than 180 mg/dL. Risk factors for hyperglycemia were assessed using multivariable logistic regression analysis. Results Sixty-five (14.7%) patients developed hyperglycemia during surgery. The independent risk factors for intraoperative hyperglycemia were an American Society of Anesthesiologists status ≥ 3 (odds ratio [OR] 6.09, 95% confidence interval [CI]: 2.67–13.89, p < 0.001), preoperative impaired fasting blood sugar (OR 2.28, 95%CI:1.13–4.61, p = 0.021), duration of anesthesia ≥ 3 h (OR 4.06, 95%CI: 1.23–13.45, p = 0.021), intraoperative hypotension (OR 5.37, 95%CI: 2.35–12.29, p < 0.001), intraoperative blood transfusion (OR 4.35, 95%CI: 2.15–8.79, p < 0.001), and steroid use (OR 2.39, 95%CI: 1.20–4.76, p = 0.013). Surgical site infection was higher in patients with intraoperative hyperglycemia compared with patients without intraoperative hyperglycemia (4 [6.1%] vs. 6 [1.6%], respectively, p = 0.035). Conclusion The incidence of intraoperative hyperglycemia was significant in non-diabetic patients during intermediate- to high-risk surgery. Risk factors should be identified to prevent intraoperative hyperglycemia. Trial registration The study was prospectively registered at https://www.thaiclinicaltrials.org (TCTR20191114001).
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