Extracorporeal Removal CO2 Using a Venovenous, Low-Flow System (Decapsmart) in a Lung Transplanted Patient: A Case Report

Background. Primary graft dysfunction (PGD) is a syndrome that may occur after lung transplantation. In some cases of severe PGD, conventional therapies like ventilatory support, administration of inhaled nitric oxide (iNO), and surfactant and intravenous prostacyclins are inadequate to achieve adequate gas exchange. The only lifesaving option is to use an extracorporeal membrane oxygenator. The Decapsmart is a new venovenous, low-flow extracorporeal device to removal carbon dioxide (CO2). It does not need a specialized staff. Herein we have presented a case report of a patient who underwent single lung transplantation and experienced respiratory failure. Methods. On November 2007, a 52-year-old woman underwent a single right lung transplantation, and developed severe PGD in the postoperative period. After institution of conventional treatments, including ventilatory and hemodynamic support, iNO, and prostaglandine El, we started treatment with Decapsmart to remove CO2. Hemodynamic and respiratory parameters were assessed at baseline and after 3, 12, 24, and 48 hours. Results. No adverse events occurred. From baseline to 48 hours, pH values increased and partial pressure of CO2 reduced. At the same time ventilatory support was reduced, thereby mitigating barotrauma and risk of overdistension. Conclusion. The use of Decapsmart may be an important aid for patients with severe respiratory acidosis in association with conventional therapy during the perioperative period after lung transplantation

Regional cerebral saturation versus transcranial Doppler during carotid endarterectomy under regional anaesthesia

Background and objective The aim of this study was to compare a cerebral oximeter with transcranial Doppler (TCD) as a neurological monitor in patients undergoing carotid endarterectomy under regional anaesthesia. Methods Forty patients were enrolled for this prospective study. We recorded every adverse neurological event after arterial clamping and variations in parameters evaluated by the two monitoring systems in order to determine whether there was any correlation between TCD data and those obtained by regional cerebral saturation, the timing of detection of the adverse event in both clinical examination and instrumental data and the presence of any false positives or negatives in any of the two monitoring systems. Results Shunting was necessary in eight patients, following clinical signs of a neurological deficit during clamping. In these patients, a significant reduction in TCD values and regional cerebral saturation values from baseline was recorded. We observed a drastic reduction in TCD values in four patients during clamping (6 +/- 5 versus 41 +/- 4 cm s(-1)) that was not associated with any neurological deficit or reduction in regional cerebral saturation values (51 +/- 4 versus 54 +/- 7%). Instrumental detection of a neurological deficit anticipated the clinical observation of about 5-10 s. Conclusion We observed a greater reliability with the cerebral oximeter than with TCD in our patients. Eur J Anaesthesiol 26:643-647 (C) 2009 European Society of Anaesthesiology

Activated recombinant factor VII in orthotopic liver transplantation

Orthotopic liver transplantation (OLT) is affected by important alterations of hemostasis. The aim of this study was to evaluate the efficacy of recombinant factor VII activated (rFVIIa) to reduce intraoperative bleeding during OLT. Methods. Twenty OLT patients were assigned in double-blind way to a rFVIIa group or a control group. Inclusion criteria were hemoglobin 8 g/dL: INR 1,5 and fibrinogen 100 mg/dL. We administered a single bouls of rFVIIa (40 g/kg) or placebo. We determined INR, partial thromboplastin time, fibrinogen, ATIII, and blood cell counts. Blood products were administered as follows: 4 units of fresh frozen plasma when INR 1.5, and 1 unit of RBC for Hb 10 g/dL. The study ended 6 hours after the bolus. Results. No thromboembolic events occurred. The INR was different between rFVIIa group and the controls at T0 (1.9 vs 1.6 P .021) and during T1 (1.2 vs 1.6 P .004). The total transfused red blood cells was 300 mL 133 in rFVIIa group and 570 mL 111 in control group (P .017). The total fresh frozen plasma was 600 mL 154 in rFVIIa group and 1400 mL 187 in control group (P .001). Total blood loss was greater in the control group than the rFVIIa group: 1140 mL 112 vs 740 mL 131 (P .049). Discussion. The use of rFVIIa during OLT can reduce the risk of bleeding during surgery. The literature has described cases who did not benefit from the treatment. An adequate cut-off of INR, allowed us to treat only patients at greater bleeding risk

Fenoldopam and gastric tonometry during ortothopic liver transplantation

The aim of this study was to evaluate the effects of continuous infusion of fenoldopam on splanchnic perfusion in orthotopic liver transplant (OLT) recipients. Patients and Methods. We enrolled 40 patients of mean age 57 16 years who underwent (OLT). They were randomly divided into two double blinded groups; continuous fenoldopam (0.06 mcg/kg per minute) or placebo infusion. Hemodynamics, gastric tonometry, urine output, renal function parameters, and diuretics use were collected during selected phases of the surgery and postoperatively every 12 hours for 72 hours in the intensive care unit. Results. No significant differences were observed between the two groups concerning hemodynamics, though in the fenoldopam group we observed increased splanchnic perfusion during the whole study period but particularly after arterial unclamping (pHi 7,31 0.04 vs 7.28 0.05; P .05) and at 48 hours after surgery (pHi 7.49 0.15 vs 7.39 0.15; P .05). Creatinine and blood urea nitrogen values were slightly higher in the placebo group, but this data did not reach statistical significance, while higher doses of furosemide were administered to the placebo group to maintain a urinary output over 200 mL/hour during the whole study. Discussion. In this study we observed that continuous fenoldopam infusion (0.06 mg/kg per minute) improved splanchnic perfusion without affecting systemic pressure. Conclusion. Patients undergoing OLT have altered splanchnic perfusion related to cirrhosis, surgical manipulation, and fluid shifts during and after surgery. The use of a splanchnic vasodilator drug improved outcomes in these patients

Modifications of intracranial pressure after molecular adsorbent recirculating system treatment in patients with acute liver failure: Case reports

Cerebral dysfunction may be fatal in patients with acute liver failure (ALF); intracranial pressure (ICP) monitoring may be mandatory to direct measures to prevent further cerebral edema. Recently the introduction of dialysis with the molecular adsorbent recirculating system (MARS) has improved the outcomes among patients with ALF. The aim of this study was to evaluate ICP changes after MARS treatment among patients with ALF. Methods. Three patients—14, 18 and 16 years old—were admitted to the ICU for acute liver failure induced by HBV in two cases and by acetaminophen in the other one. Because of Glasgow Coma Score (GCS)8, they were intubated and ventilated to protect the airway and maintain moderate hypocapnia. Invasive monitoring of intracranial pressure MARS treatments were performed in all patients. Results. The patients received MARS treatments every day after their admission to liver transplantation. After MARS therapy the ICP decreased on average from 21 to 7 mm Hg. Significant hemodynamic modifications were not observed and their neurogical conditions improved. Conclusion. MARS treatment improved the clinical pictures of these patients increasing the available time to obtain an urgent liver graft

Clinical effects of use polymyxin B fixed on fibers in liver transplant patients with severe sepsis or septic shock

Abstract: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component exclusively found in gram-negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed: PMX is covalently bound to the surface of an insoluble carrier material to inactivate endotoxin in blood without exerting toxicity on the brain or the kidney. The aim of this study was to evaluate the efficacy, safety, and clinical effects of direct hemoperfusion with an immobilized polymyxin B fiber column (DHP-PMX) among liver transplant patients with severe sepsis or septic shock. Methods. From June 2004 to May 2005, 10 patients (6 men and 4 women) of overall mean age of 55 years (46-65 range) underwent orthotopic liver transplantation (OLT) and developed severe sepsis or septic shock according to The Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all treated patients who received conventional antibiotic therapy, vasopressor or inotropic agents, and ventilatory support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters and dosages of vasopressor or inotropic drugs were assessed at baseline and after each treatment. Results. No adverse events occurred. From baseline to the third treatment the mean arterial pressure increased from 64 +/- 5 mm Hg to 89 +/- 4 rum Hg; while the dosages of dobutamine and norepinephrine were reduced: 6.4 to 1 mcg/kg/min and 1.3 to 0.001 mcg/kg per min, respectively. The PaO2/FiO(2) ratio increased: 214 to 291 mm Fig. Conclusion. The use of DHP-PMX may be an important aid in patients with sepsis in association with conventional therapy

Incidence of fungal infections in a solid organ recipients dedicated intensive care unit

Abstract: Invasive fungal infections are a significant cause of morbidity and mortality for patients undergoing solid organ transplantation. Our aim was to evaluate the incidence of invasive fungal infections in solid organ recipients within a dedicated intensive care unit (ICU). Materials and Methods. From May 2002 to May 2005, 278 patients undergoing solid organ transplantation (105 liver, 142 kidney, 20 lung, 2 combined liver-kidney, 9 combined pancreas-kidney) were admitted to our posttransplant intensive care unit. We retrospectively analyzed data obtained from the ICU stay. Fungal infection was defined by positivity of normally sterile biological samples and by elevated positivity of normally non sterile biological samples. We did not consider superficial fungal infections and asymptornatic colonizations. Results. Forty-six patients (16.5%) developed a fungal infection; at least one mycotic agent was isolated from each patient. Candida albicans was the most common pathogen, isolated from 71% of infected patients (33 of 46). Infected patients showed a mortality rate of 35%, while that for non infected recipients was 3.5%. Total length of ICU stay was the most significant risk factor among infected patients (30.26 days vs 5.04 days P <.0001). Mean time between transplantation and first positive samples was 6.17 days (SD 8.88). Conclusion. Fungal infections in solid organ transplant patients are a major issue because of their associated morbidity and mortality. Candida albicans was the most common pathogen and total lenght of ICU stay was the most important risk factor

Clinical effects of direct hemoperfusion using a polimyxin-B immobilized column in solid organ transplanted patients with signs of severe sepsis and septic shock. A pilot study.

Abstract: Background: Polymyxin B (PMX-B) is a polycationic antibiotic, known to bind the lipid A portion of endotoxin, a cell wall component found exclusively in gram negative bacteria (GNB). An extracorporeal hemoperfusion device (TORAYMYXIN) has been developed. PMX is covalently bound on the surface of an insoluble carrier material so that the endotoxin can be inactivated in the blood without exerting its toxicity on the brain and kidney. The aim of this study was to clarify the efficacy, safety and clinical effects of direct hemoperfusion with an immobilized polymyxin-B fiber column (DHP-PMX) in solid organ transplanted patients with severe sepsis or septic shock. Methods: From June 2004 to May 2005, 15 patients (10 men and 5 women), mean age 55 years old (46-65 range), underwent kidney or liver transplantation and developed severe sepsis or septic shock, as defined by the Consensus Conference of American College Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. GNB were detected in all the patients receiving conventional treatments including antibiotic therapy, vasopressive or inotropic agents, and ventilation support. The DHP-PMX treatment was performed three times in each patient. Hemodynamic and respiratory parameters, dosage of vasopressor/inotropic drugs were assessed at baseline and after each treatment. Results: No adverse events occurred. From baseline to 3rd treatment, mean arterial pressure (MAP) was increased (from 63+/-5 to 83+/-4 mmHg), while the dosage of dobutamine (from 7.5+/-3 to 3+/-2 mcg/kg/min) and noradrenaline (from 1.3+/-0.45 to 0.05+/-0.02 mcg/kg/min) were reduced. The PaO2/FiO(2) ratio increased (from 234+/-38.47 to 290+/-107.48 mmHg). Conclusion: The use of DHP-PMX in association with conventional therapy may be an important aid in patients with sepsis