Preoperative cardiac assessment in liver transplant candidates

New and extended indications, older age, higher cardiovascular risk, and the long-standing cirrhosis-associated complications mandate specific skills for an appropriate preoperative assessment of the liver transplant (LT) candidate. The incidence of cardiac diseases (dysrhythmias, cardiomyopathies, coronary artery disease, valvular heart disease) are increasing among LT recipients: however, no consensus exists among clinical practice guidelines for cardiovascular screening and risk stratification. In spite of different "transplant center-centered protocols", basic "pillars" are common (electrocardiography, baseline echocardiography, functional assessment). Owing to intrinsic limitations, yields and relevance of noninvasive stress tests, under constant scrutiny even if used, are discussed, focusing the definition of the "high risk" candidate and exploring noninvasive imaging and new forms of stress imaging. The aim is to find an appropriate and rational stepwise algorithm. The final commitment is to select the right candidate for a finite resource, the graft, able to save (and change) lives

SIAMOC position paper on gait analysis in clinical practice: General requirements, methods and appropriateness. Results of an Italian consensus conference

Gait analysis is recognized as a useful assessment tool in the field of human movement research. However, doubts remain on its real effectiveness as a clinical tool, i.e. on its capability to change the diagnostic-therapeutic practice. In particular, the conditions in which evidence of a favorable cost-benefit ratio is found and the methodology for properly conducting and interpreting the exam are not identified clearly. To provide guidelines for the use of Gait Analysis in the context of rehabilitation medicine, SIAMOC (the Italian Society of Clinical Movement Analysis) promoted a National Consensus Conference which was held in Bologna on September 14th, 2013. The resulting recommendations were the result of a three-stage process entailing i) the preparation of working documents on specific open issues, ii) the holding of the consensus meeting, and iii) the drafting of consensus statements by an external Jury. The statements were formulated based on scientific evidence or experts' opinion, when the quality/quantity of the relevant literature was deemed insufficient. The aim of this work is to disseminate the consensus statements. These are divided into 13 questions grouped in three areas of interest: 1) General requirements and management, 2) Methodological and instrumental issues, and 3) Scientific evidence and clinical appropriateness. SIAMOC hopes that this document will contribute to improve clinical practice and help promoting further research in the field

Solid Organ Transplantation During COVID-19 Pandemic: An International Web-based Survey on Resources’ Allocation

Background. Solid organ transplants (SOTs) are life-saving interventions, recently challenged by coronavirus disease 2019 (COVID-19). SOTs require a multistep process, which can be affected by COVID-19 at several phases. Methods. SOT-specialists, COVID-19-specialists, and medical ethicists designed an international survey according to CHERRIES guidelines. Personal opinions about continuing SOTs, safe managing of donors and recipients, as well as equity of resources' allocation were investigated. The survey was sent by e-mail. Multiple approaches were used (corresponding authors from Scopus, websites of scientific societies, COVID-19 webinars). After the descriptive analysis, univariate and multivariate ordinal regression analysis was performed. Results. There were 1819 complete answers from 71 countries. The response rate was 49%. Data were stratified according to region, macrospecialty, and organ of interest. Answers were analyzed using univariate- multivariate ordinal regression analysis and thematic analysis. Overall, 20% of the responders thought SOTs should not stop (continue transplant without restriction); over 70% suggested SOTs should selectively stop, and almost 10% indicated they should completely stop. Furthermore, 82% agreed to shift resources from transplant to COVID-19 temporarily. Briefly, main reason for not stopping was that if the transplant will not proceed, the organ will be wasted. Focusing on SOT from living donors, 61% stated that activity should be restricted only to "urgent"cases. At the multivariate analysis, factors identified in favor of continuing transplant were Italy, ethicist, partially disagreeing on the equity question, a high number of COVID-19- related deaths on the day of the answer, a high IHDI country. Factors predicting to stop SOTs were Europe except-Italy, public university hospital, and strongly agreeing on the equity question. Conclusions. In conclusion, the majority of responders suggested that transplant activity should be continued through the implementation of isolation measures and the adoption of the COVID-19-free pathways. Differences between professional categories are less strong than supposed

Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement

Introduction: Hydroxyethyl starch (HES) is a commonly used colloid in critically ill patients. However, its safety has been questioned in recent studies and meta-analyses. Methods: We re-evaluated prospective randomised controlled trials (RCT) from four meta-analyses published in 2013 that compared the effect of HES with crystalloids in critically ill patients, focusing on the adherence to 'presumably correct indication'. Regarding the definition of 'presumably correct indication', studies were checked for the following six criteria (maximum six points): short time interval from shock to randomisation (<6 h), restricted use for initial volume resuscitation, use of any consistent algorithm for haemodynamic stabilisation, reproducible indicators of hypovolaemia, maximum dose of HES, and exclusion of patients with pre-existing renal failure or renal replacement therapy. Results: Duration of fluid administration ranged from 90 min up to a maximum of 90 days. Four studies considered follow-up until 90-day mortality, three studies 28-/30-day mortality, whereas four studies reported only early mortality. Included studies showed a large heterogeneity of the indication score ranging between 1 and 4 points with a median (25%; 75% quartile) of 4 (2; 4). Conclusions: The most important question, whether or not HES may be harmful when it is limited to immediate haemodynamic stabilisation, cannot be answered yet in the absence of any study sufficiently addressing this question. In order to overcome the limitations of most of the previous studies, we now suggest an algorithm emphasising the strict indication of HES. Additionally, we give a list of suggestions that should be adequately considered in any prospective RCT in the field of acute volume resuscitation in critically ill patients

Active methylene compounds in asymmetric organocatalytic synthesis of natural products and pharmaceutical scaffolds

International audienceLast decades have witnessed the golden rush of organocatalysis, which opened an effective and efficient way to high yielding, metal free, stereoselective strategies toward the synthesis of a plethora of natural products. The present review provides an overview of the current achievements of those organocatalytic methodologies in which active methylene compds. have been used as key intermediates. Ranging from covalent to non-covalent activation mode, from monofunctional to bifunctional catalysts, recent results suggest a variety of new powerful tools to accomplish the formal and total synthesis of both the simplest and the most complex natural compds. with facile procedures in high yields and excellent stereoselectivities. At the same time, it is clear how the organocatalytic approach might offer an outstanding and impressive answer to unsolved longstanding synthetic challenges. Finally the possible application to industrial protocols and to the prepn. of novel potential drugs has been highlighted

Management of Severe Bleeding in Liver Disease and Transplantation

The concept that patients with cirrhosis are at increased risk of bleeding events is probably out of date. Liver failure is accompanied by multiple changes in the hemostatic system, because of reduced plasma levels of procoagulative and anticoagulative clotting factors synthesized by the intact liver. Thrombocytopenia is very frequent ranking first among the altered hematological tests but Von Willebrand factor is elevated and ADAMTS-13 instead decreased, counterbalancing/compensating in some way the thrombocytopenia. The hemostatic system is then in a delicate balance between prothrombotic and antithrombotic processes. Since the global effect of liver disease on the hemostatic system is complex, patients with end-stage liver disease (ESLD) can experience severe bleeding or, at the opposite, thrombotic complications. Conventional coagulation tests such as prothrombin time (PT) and international normalized ratio (INR) are not able to provide information on the actual coagulation status of the patient as well as to predict possible bleeding or thrombotic events in patients with liver disease. Standard hemostatic tests which are inadequate to evaluate the so-called rebalanced hemostatic profile of the cirrhotic patient may provide misleading information regarding the risk of bleeding: in particular, clinicians have to be aware that unneeded, useless, or even dangerous pro-hemostatic factors might be administered with no demonstrated benefit. Because of the limits of conventional coagulation tests, in recent years, the viscoelastic tests (Thromboelastography/thromboelastomatry) have gained increasing importance. A more dynamic and targeted approach to the overall hemostatic process is at the base of their success providing a visual information on fibrinolysis, on the presence of endogenous heparinoids and tendency to hypercoagulability: these characteristics make these tests ideal for a rapid diagnosis of the type of coagulopathy and for an appropriate choice of the therapeutic option in patients with acute or chronic liver disease

Early alterations of red blood cell rheology in critically ill patients

SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Clinical standards for patient blood management and perioperative hemostasis and coagulation management position paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new 'standard of care' so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multi- professional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period

From the Physiology to the Bedside: Fluid Therapy in Cardiac Surgery and the ICU

Purpose of Review In this review, we summarize the evidence present in the literature about this important field, with particular attention to the peculiarities of cardiac surgery. Recent Findings Since water is the main component of human cells and tissue, together with electrolytes and proteins, the manipulation of this element in critical illness is a powerful tool in the hands of the anesthesiologist and intensive care doctor. It can be either extraordinarily effective in the treatment of the patient’s disease and in correcting the hemodynamic instability or it can lead to very dangerous consequences, such as edema or end-organ damage. The potential consequences of this therapy require a proper monitoring system and the possibility to correctly assess the probability of the patient to respond to a fluid bolus in the macro- and microhemodynamics. Summary Fluid therapy has potentially enormous advantages when the indication is correctly given and balanced to the potential side effects