Opioid-induced hyperalgesia and rapid opioid detoxification after tacrolimus administration

Opioids can induce central sensitization and hyperalgesia, referred to as "opioid-induced hyperalgesia." Our report describes a patient who underwent intestinal transplant followed by immunosuppressant-related neuropathic pain. Her pain was treated with limited success over the course of 3 yr with different therapies, including i.v. morphine. She developed opioid-induced hyperalgesia, which was successfully treated with rapid detoxification under general anesthesia. Detoxification improved her quality of life, including the ability to resume physiotherapy. Six months after treatment, she remained opioid free. Our experience suggests that rapid detoxification under general anesthesia may be an effective treatment for opioid-induced hyperalgesia and merits comparison to traditional detoxification methods

Metabolic, coagulative, and Hemodynamic changes during intestinal transplant: good predictors of postoperative damage?

BACKGROUND.: Analysis of intraoperative changes of metabolic, hemodynamic, and coagulative parameters is useful to detect early ischemia-reperfusion damage after intestinal transplant. METHODS.: The objective of our study is to correlate the histological damage at the end of transplant in relation to the intraoperative changes after reperfusion. The histological aspect was graded according to Park's classification at the end of the surgical procedure with biopsies of the graft. Patients were divided into two groups according to the presence or absence of histological damage of the small bowel wall: group A (normal mucosa/minimal damage: Park's grades 0-1) and group B (mucosal damage: Park's grades 2-8). RESULTS.: Significant hemodynamic, metabolic, and coagulative disorders were observed in group B. Consequently, these disorders are thought to be early indicators of graft damage. CONCLUSIONS.: Actual monitoring procedures used for postoperative graft surveillance remain paramount in detecting postoperative intestinal dysfunction, but the indicators described in this paper could represent a further help in intraoperative and postoperative managemen

Metabolic, coagulative, and hemodynamic changes during intestinal transplant: Good predictors of postoperative damage?

BACKGROUND. Analysis of intraoperative changes of metabolic, hemodynamic, and coagulative parameters is useful to detect early ischemia-reperfusion damage after intestinal transplant. METHODS. The objective of our study is to correlate the histological damage at the end of transplant in relation to the intraoperative changes after reperfusion. The histological aspect was graded according to Park's classification at the end of the surgical procedure with biopsies of the graft. Patients were divided into two groups according to the presence or absence of histological damage of the small bowel wall: group A (normal mucosa/minimal damage: Park's grades 0-1) and group B (mucosal damage: Park's grades 2-8). RESULTS. Significant hemodynamic, metabolic, and coagulative disorders were observed in group B. Consequently, these disorders are thought to be early indicators of graft damage. CONCLUSIONS. Actual monitoring procedures used for postoperative graft surveillance remain paramount in detecting postoperative intestinal dysfunction, but the indicators described in this paper could represent a further help in intraoperative and postoperative management. © 2007 Lippincott Williams & Wilkins, Inc

Analysis of cardiovascular, acid-base status, electrolyte, and coagulation changes during small bowel transplantation

The analysis of intraoperative hemodynamic, metabolic, and coagulation disorders of the recipients in relation to the newly reperfused organ during intestinal transplantation is necessary for an optimal patient management during small bowel transplantation (SBT). The interaction may be minor or may lead to postreperfusion syndrome, producing intense hemodynamic instability, important metabolic changes, and coagulation disorders. This research is based upon experience with 27 patients who underwent SBT. We observed significant decreases in PAM and IRVS after reperfusion in accordance with minor changes of mean pulmonary artery pressure, central venous pressure, and pulmonary capillary wedge pressure. The fall in pH upon revascularization was associated with a concomitant rise in partial carbon dioxide pressure probably due to the increased metabolic activity of the new organ. We found a significant increase in K levels, a rise that may be due to the output of metabolic products by the donor intestine. Patients displayed an hypocoagulative pattern, a derangement that did not seem to depend on ischemia time. It is possible that the same factors supporting the initial TEG pattern endure throughout the surgical procedure. The important and significant maximum amplitude indicator variation between the initial value and that after reperfusion may relate to the release of hypocoagulative factors superimposed on background abnormalities. These interesting metabolic disorders presumably reflected graft function and may provide predictive indices for a good outcome. © 2006 Elsevier Inc. All rights reserved

Post-reperfusion syndrome during isolated intestinal transplantation. Outcome and predictors

Background: Post-reperfusion syndrome (PRS) during isolated intestinal transplantation (ITx) is characterized by decreased systemic blood pressure, systemic vascular resistance, and cardiac output and by a moderate increased pulmonary arterial pressure. We hypothesize that the more severe PRS causes a poorer long-term outcome. The primary aim of this study was to determine the independent clinical predictors of intra-operative PRS, as well as to investigate the link between the severity of PRS and the intra-operative profiles and to examine the post-operative complications and their relationship with transplant outcome. Methods: This observational study was conducted on 27 patients undergoing isolated ITx in a single adult liver and multivisceral transplantation center. PRS was considered when the mean arterial blood pressure was 30% lower than the pre-unclamping value and lasted for at least one min within 10 min after unclamping. Results and conclusions: The main results of this study can be summarized in two findings: in patients undergoing ITx, the duration of cold ischemia and the pre-operative glomerular filtration rate were independent predictors of PRS and the occurrence of intra-operative PRS was associated with significantly more frequent post-operative renal failure and early post-operative death