Hyperdynamic circulation in cirrhosis: predictive factors and outcome following liver transplantation.

BACKGROUND: Liver cirrhosis is associated with a hyperdynamic circulation (HC). In this observational study, we aimed to investigate the predictive factors of HC, its impact on intraoperative hemodynamic and postoperative outcome, early ICU and in-hospital mortality, in cirrhotic patients undergoing orthotopic liver transplantation (OLT). METHODS: Two hundred and forty-two patients with cirrhosis undergoing cadaveric OLT were included. Before starting the transplant procedure and under general anesthesia, a pulmonary artery catheter was introduced to assess hemodynamic parameters. The baseline assessment was carried out approximately 30 minutes after the catheter placement and repeated during the anhepatic phase, 10 minutes after the reperfusion and at the end of surgery. The patients were divided into two groups: in group 1 the patients had SVR>900dynes s-1 m-2 cm-5, in group 2 SVR ≤900 dynes s-1 m-2 cm-5. RESULTS: Eighty-two patients (33%) presented severe HC. In multivariate analysis 2 factors were associated with the occurrence of HC: beta-blockers use (Exp [B]=4.42 (95% CI 1.18-17); P=0.001, [34% and 12% in groups 1 and 2, P<0.001, respectively]) and model for end-stage liver disease (MELD) score (Exp [B]=1.066; 95% CI=1.025-1.109; P=0.001). CONCLUSION: MELD score was an independent predictor of HC, and beta-blockers resulted associated with lower incidence of HC in cirrhotic patients undergoing cadaveric OLT. Intraoperative HC correlates with hemodynamic alterations, requiring more blood products and vasopressor use, this may increase the risk of renal failure, early ICU death and in-hospital mortality

Long-lasting beneficial effects of periradicular injection of meloxicam for treating chronic low back pain and sciatica

BACKGROUND: Chronic low back pain (LBP) and sciatica can occur without obvious structural causes and are often resistant to conventional analgesic drugs. The effect of periradicular injection of meloxicam on LBP with or without a radicular component was assessed. A secondary objective of this prospective observational study was to assess the effect of meloxicam on functional recovery. METHODS: Seventy-two patients (30 men, 42 women) with LBP and/or sciatica were followed for 90 days to six years after injecting 10 mg meloxicam in 10 mL saline at each of the involved dermatomal levels. A standard verbal rating scale (VRS) from 0=no pain to 10=severe pain was used for assessing LBP before the injection of meloxicam (at baseline) and at 1, 5, 10, 30 and 60 min, and 1, 5, 15, 30 and 90 days intervals after the injection. The meloxicam injection was repeated only if the VRS score remained >3. Rescue analgesic requirements and functional activity levels were also assessed from 30-90 days after the last injection of meloxicam. RESULTS: The mean baseline LBP score was 8.60 \ub1 1.50 (SD) despite the use of multi-modal analgesic regimens (NSAIDs, glucocorticosteroids, paracetamol, oral opioids, gabapentanoid compounds, epidural or periradicular steroid and/or local anesthetics) as well as laser treatments and physical therapy. The majority of patients reported that their pain intensity decreased by ~50% 1-2 min after the meloxicam injection was completed. Thirty-six patients (50%) required no further injections, 25 patients (35%) required a second injection after seven days, and 11 patients (15%) required a total of three injections. After the meloxicam treatment(s), only 10 patients (14%) required "rescue" analgesia with oral NSAIDs. All patients were able to increase their level of functional activity after the meloxicam treatment(s). CONCLUSION: Periradicular injections of meloxicam (10 mg) appear to be a useful alternative to opioid and non-opiod analgesics for patients with intractable LBP due to nerve root inflammation

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

Treatment of chronic cervicobrachial pain with periradicular injection of meloxicam

Background: Cervicobrachial pain (CBP) is often resistant to conventional oral analgesics. We hypothesized that periradicular injection of meloxicam would produce a significant reduction in intractable CBP. The secondary objective was to assess the impact on functional recovery. Methods: 48 patients with persistent CBP despite multimodal analgesic therapy received 1-3 periradicular injections of meloxicam, 5-20 mg, at the dermatomal level(s) corresponding to their pain symptoms. Pain level (0=none to 10=severe), rescue analgesics and functional activity were recorded at baseline for 90 days after the last injection. The injection was repeated if the pain score remained >3 or paraesthesia persisted. Results: The mean pain score was reduced from a baseline of 8.9 (\ub11, SD) to 1.7 (\ub12.2, SD) at 90 days after the last meloxicam injection. After the meloxicam treatment(s), only 13% of the patients required oral analgesics as rescue medication. All patients increased their functional activity level. Conclusion: Cervical periradicular injection of meloxicam reduced CBP by 81% at 90d and improved functional recovery

Post-reperfusion syndrome during isolated intestinal transplantation: outcome and predictors

Post-reperfusion syndrome (PRS) during isolated intestinal Background: 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 This observational study was conducted on 27 with transplant outcome. Methods: patients undergoing isolated ITx in a single adult liver and multivisceral transplantation center. PRS was considered when the mean arterial blood pressure min was 30% lower than the pre-unclamping value and lasted for at least one The main results of min after unclamping. Results and conclusions: within 10 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

Soft Tissue Depression at the iliac crest prominence: a new landmark for identifying L4-L5 Interspace.

BACKGROUND: One of the most common approaches to identifying the L4-L5 interspace is using the iliac crest as a landmark. We propose a new landmark to identify the L4-L5 interspace based on the soft tissue depression palpable at the iliac crest prominence. The aim of this study was to assess the reliability and time saving when using this new landmark compared to using the iliac crest to perform a lumbar plexus block. METHODS: Fifty-four patients scheduled for lower limb surgery were randomly allocated to have a lumbar plexus block performed using the iliac crest (Chayen's approach) or the soft tissue depression (Borghi's approach). The landmarks for both approaches were drawn on each patient prior to randomization (N.=27 per group). All the blocks were performed by an anesthesiologist familiar with both techniques using a nerve stimulator and 30 mL of 0.5% levobupivacaine. The time to achieve successful needle placement and the number of needle re-directions, as well as the onset time for the sensory and motor blockade, were recorded. RESULTS: All the blocks using Borghi's approach were performed successfully. With the Chayen's approach, there were 5 needle placement failures. The mean times to onset of a successful block after injection of the local anesthetic did not differ between the two groups: 17.8\ub13.9 min for the Chayen vs. 15.9\ub12.4 min for the Borghi's approach (P=0.14). However, the mean time to achieve correct needle placement was 7.6\ub13.2 min with the Chayen's approach compared to 5.1 (\ub12.6 SD) min with the Borghi's approach (P<0.01). The Chayen's approach also required a significantly higher median number of needle redirections (2 [inter-quartile range (IQR): 0-4] vs. 0 [IQR: 0-4], P<0.01). In obese patients (BMI 6530 kg/m(2)), the mean placement time was 10.5\ub11.7 min vs. 4.8\ub12.1 min (P<0.01), and median number of needle re-directions was 2.5 (IQR: 2-3) vs. 0.5 (IQR: 0-3) (P=0.04), with the Chayen and Borghi's approach, respectively. CONCLUSION: Use of the palpable soft tissue depression at the iliac crest prominence for performing a lumbar plexus block offered several potential advantages over the standard inter-iliac crest approach

Anesthesia for liver transplantation: the experience of the University of Bologna in the MELD era.

AIM: The hepatic cirrhosis is associated with an important cardiovascular alterations. In this report, we review our transplant center experience with liver transplantation in the Model for End-Stage Liver Disease (MELD) era, in particular this study investigate the relationship between severity of liver disease assessed by MELD score and postoperative events. METHODS: Our retrospective review was performed on 242 cirrhotic patients underwent liver transplanation at the Department of Surgery and Transplantation of the University of Bologna. Biochemical and hemodynamic variables were evaluated by Swan-Ganz catherization. Dindo's classification of postoperative complications was used for the evaluation of postoperative course. RESULTS: Morbidity occurred in 158 patients (65.2%) and 13 patients died during the hospital stay. Considering the highest grade of complication occurred, non life-threatening complications occurred in the 47.9% of cases (116 patients) and life-threatening complications, excluding patient death, in 17.3% (42 patients). Patients with MELD >30 showed a longer ICU stay, tracheal intubation and in-hospital stay. CONCLUSION: In conclusion MELD score is tightly related to postoperative complications