Peak Serum AST Is a Better Predictor of Acute Liver Graft Injury after Liver Transplantation When Adjusted for Donor/Recipient BSA Size Mismatch (ASTi)

Background. Despite the marked advances in the perioperative management of the liver transplant recipient, an assessment of clinically significant graft injury following preservation and reperfusion remains difficult. In this study, we hypothesized that size-adjusted AST could better approximate real AST values and consequently provide a better reflection of the extent of graft damage, with better sensitivity and specificity than current criteria. Methods. We reviewed data on 930 orthotopic liver transplant recipients. Size-adjusted AST (ASTi) was calculated by dividing peak AST by our previously reported index for donor-recipient size mismatch, the BSAi. The predictive value of ASTi of primary nonfunction (PNF) and graft survival was assessed by receiver operating characteristic curve, logistic regression, Kaplan-Meier survival, and Cox proportional hazard model. Results. Size-adjusted peak AST (ASTi) was significantly associated with subsequent occurrence of PNF and graft failure. In our study cohort, the prediction of PNF by the combination of ASTi and PT-INR had a higher sensitivity and specificity compared to current UNOS criteria. Conclusions. We conclude that size-adjusted AST (ASTi) is a simple, reproducible, and sensitive marker of clinically significant graft damage

Cardiac function after hepatic ischemia-anoxia and reperfusion injury: A new experimental model

BACKGROUND AND METHODSDuring liver transplantation, reperfusion of the donor liver and in the clinical setting, end-stage liver disease, have occasionally resulted in profound cardiovascular disturbances. The etiology of hepatic injury-induced myocardial dysfunction is still unclear. In this study, the aims were to develop an experimental model that would facilitate the study of the effects of hepatic failure on myocardial function and to determine whether hepatic ischemia or anoxia and reperfusion injury of similar duration would result in the same degree of hepatic failure.Seventy male Sprague-Dawley rats were used as organ donors. Three simultaneous liver-heart perfusions (corresponding to three groups) were established using a modified Krebs-Henseleit buffer with 2% bovine albumin, membrane oxygenation, and a peristaltic pump. Group 1 (n = 10) and group 2 (n = 15) experiments consisted of liver-heart perfusions after 90 mins of normothermic hepatic ischemia or 90 mins of hepatic anoxia, respectively, followed by reoxygenation and 60 mins of reperfusion. Group 3 (n = 8) experiments consisted of sham liver-heart perfusions studied over the same experimental time period (60 mins). Myocardial function variables, liver function tests, arterial blood gases, and electrolytes were measured at baseline and at 3-, 10-, 30-, and 60-min intervals during reperfusion in all experiments. RESULTSIschemia or anoxia-induced hepatic failure resulted in a similar degree of hepatic dysfunction. Both forms of acute hepatic failure caused significant increases in liver function tests, a reduction in heart rate (p < .05), coronary flow (p < .05), and an increase in calculated coronary vascular resistance (p <.05). There were no changes in buffer pH, CO2, or ionized calcium that could explain the coronary vasoconstriction. CONCLUSIONSHepatic dysfunction induced by ischemia or anoxia of similar duration results in a similar hepatic metabolic profile during reperfusion and can cause direct myocardial dysfunction of the isolated perfused rat heart

Assessment of Prehospital and Hospital Response in Disaster

The problems associated with assessment of the response of a prehospital /hospital system to a disaster will be less severe if they are addressed to some degree in the disaster plan. A general protocol for assessment could be developed as part of the disaster planning effort and evaluation staff could tentatively be identified by position (e.g., emergency department medical director). The issue of data availability could be confronted and provisions made for the recording of at least minimal information on patient log forms under disaster conditions

National Medical Response to Mass Disasters in the United States: Are We Prepared?

Preparing for a resuscitation response to mass disasters, such as major earthquakes or industrial disasters, requires revisions of present local, regional, and national disaster plans. These should include the following: (1) life-supporting first aid and basic rescue capability of the lay public; (2) advanced trauma life support and advanced (heavy) rescue capability brought quickly to the scene from local and surrounding (regional) emergency medical services systems; and (3) trauma hospitals sending medical resuscitation teams to, and receiving casualties from, the disaster scene for resuscitative surgery and definitive care. Local and regional everyday emergency medical services systems would respond first. The armed forces should help, at least for transport and security. We propose that the National Disaster Medical System replace its civil defense model with an emergency medical services model, designed to mobilize rapid support for local emergency medical services systems from regional, state, and national resources. Coordination should be by one federal agency, such as the Federal Emergency Management Agency, which, however, needs to focus more on resuscitation through physician input.(JAMA. 1991;266:1259-1262

Resuscitation in a Multiple Casualty Event

A major weakness in the emergency medical response to multiple casualty events continues to be the resuscitation component, which should consist of the systematic application of basic, advanced, and prolonged life support and definitive care within 24 hours. There have been major advances in emergency medical care over the last decade, including the feasibility of point-of-care ultrasound to aid in rapid assessment of injuries in the field, damage control resuscitation, and resuscitative surgery protocols, delivered by small trauma/resuscitation teams equipped with regional anesthesia capability for rapid deployment. Widespread adoption of these best practices may improve the delivery of resuscitative care in future multiple casualty events

The effect of methylene blue during orthotopic liver transplantation on post reperfusion syndrome and postoperative graft function

Background/Purpose In orthotopic liver transplantation (OLT), a major component of the post‐reperfusion syndrome is hypotension, which may lead to additional graft liver ischemia‐reperfusion injury. A proposed mechanism of reperfusion hypotension is the massive induction of oxidative stress triggering the release of pro‐inflammatory mediators, including nitric oxide (NO). Methylene blue (MB) is an inhibitor of inducible NO synthase and an NO scavenger that has been shown to attenuate reperfusion hypotension. Of note, recent reports have shown that the exogenous administration of NO during OLT significantly improved the recovery of the graft liver. Therefore, we sought to investigate the effects of MB on the functional recovery of the graft liver following OLT. Methods We analyzed retrospective data from 715 patients who underwent OLT between 2003 and 2008. We classified patients into those who received a 1–1.5 mg/kg intravenous bolus of MB immediately prior to reperfusion (MB group) and those who did not (control group). Propensity score matching was used to adjust for differences between patients who received intraoperative MB and those who did not, and these data were used to determine the association between a single MB bolus during OLT and postoperative graft dysfunction. Results Our study cohort consisted of 715 OLT patients, of whom 105 received MB and 610 did not. After propensity score matching, demographic and donor data were similar in the two groups, except for the older age of recipients in the MB group (55.5 ± 0.9 vs 53.1 ± 0.8 years,p = 0.026). No differences were seen in mean arterial pressure changes after reperfusion and no differences were found in vasopressor requirements (bolus or infusion) or transfusion requirements. In addition, there was no significant difference in the incidence of primary nonfunction, retransplantation within 60 days, acute rejection, or graft survival between the groups by multivariate analysis or Kaplan–Meier survival analysis. Conclusions In our study, the administration of MB at 1–1.5 mg/kg immediately prior to reperfusion did not prevent post‐reperfusion hypotension and did not decrease vasopressor usage or transfusion requirements after reperfusion. Also, MB did not have any impact on postoperative graft function. These findings may argue against the routine use of MB during OLT