Paradox: Does liver insuffi ciency protect the patient? A hypothesis

Despite the fact that the key role of the liver in the formation of the immune response to injury is not in doubt, the mechanisms of weakening the immune response to infectious and noninfectious lesions in patients with hepatic failure remain unclear. We propose an original hypothesis of forming the ways to limit the amplitude of the systemic inflammatory response in patients with the end-stage liver disease. The basis of the hypothesis is the idea that as a result of reducing the intensity of the natural stimulation of membrane mCD14 receptors by the ligands of infectious nature, the basic mechanism of the systemic immune response induction by liver macrophages (Kupffer cells) is interrupted. According to the proposed hypothesis, in condition of liver failure, the synthesis of lipopolysaccharide-binding protein by hepatocytes is reduced. This leads to a decreased amplitude and intensity of the protective immune responses. This fact explains a number of clinical phenomena observed in patients with liver failure/dysfunction that consist in a reduced reactivity of the organism to the damage inflicted by infectious and noninfectious agents. The authors consider it possible to use this hypothesis in the search for new trends to prevent the immune system hyper-reactivity in sepsis, and to improve the therapeutic strategies for the management of patients at high risk of infectious complications after liver transplantation

СРАВНИТЕЛЬНАЯ ОЦЕНКА СИМПАТИЧЕСКОЙ БЛОКАДЫ ПРИ ГРУДНОЙ ЭПИДУРАЛЬНОЙ И БИЛАТЕРАЛЬНОЙ ПАРАВЕРТЕБРАЛЬНОЙ АНЕСТЕЗИЯХ ПРИ ОПЕРАЦИЯХ ВЫСОКОЙ ТРАВМАТИЧНОСТИ НА ОРГАНАХ ВЕРХНЕГО ЭТАЖА БРЮШНОЙ ПОЛОСТИ

Objective: to compare the degree of sympathetic blockade caused by thoracic epidural or bilateral paravertebral anesthesia. Superior mesenteric artery blood flow was measured calculating the coefficient of flow resistance (resistance index) as an indicator of the degree of sympathetic block in patients undergoing high-traumaticity operations on the upper abdominal organs under thoracic epidural or bilateral paravertebral anesthesia. The patients of both groups were noted to develop sympathetic blockade with a statistically significant reduction in vascular resistance (resistance index) of the superior mesenteric artery and with an increase in blood flow in the visceral bed. The degree of sympathetic blockade was statistically significantly higher in patients under epidural anesthesia. Conclusion. Bilateral thoracic paravertebral blockade decreases sympathetic nervous system activation and may be used during high-traumaticity surgery if there are existing or predictable contraindications to epidural anesthesia. Цель исследования - сравнение выраженности симпатической блокады, обусловленной грудной эпидуральной или билатеральной паравертебральной анестезией. Проведены измерения кровотока по верхней брыжеечной артерии с расчётом коэффициента сопротивления потоку (индекса резис­тентности) как показателя выраженности симпатического блока у пациентов, которым выполняли высокотравматичные операции на органах верхнего этажа брюшной полости в условиях грудной эпидуральной или билатеральной паравертебральной анестезии. У пациентов обеих групп отмечались развитие симпатической блокады со статистически значимым снижением сосудистого сопротивления (индекса резистентности) верхней брыжеечной артерии и увеличение кровотока в висцеральном бассейне. Выраженность симпатической блокады была статистически значимо выше у пациентов с эпидуральной анестезией. Заключение. Билатеральная грудная паравертебральная блокада снижает активацию симпатичес­кой нервной системы и может быть применена при выполнении оперативных вмешательств высокой травматичности при имеющихся или прогнозируемых противопоказаниях к проведению эпидуральной анестезии

Blood pressure monitoring during liver transplantation: the method of measurement does matter

Introduction. Accurate blood pressure (BP) measurements are the mainstay for the efficient management of abrupt changes of hemodynamics and perfusion during orthotopic liver transplantation (OLT).Material and methods. The prospective study included 39 patients. We compared the BP values measured in the femoral and radial arteries during the different phases of the OLT.Results. The central systolic arterial pressure (SAP) and mean arterial pressure (MAP) measured invasive in the femoral artery were significantly higher than those measured in the peripheral artery during the anhepatic phase (95.1±10.6 vs. 84.5±9.9 mm Hg, and 66±8.8 vs. 59.7±7.1 mm Hg, respectively), after 5 minutes of reperfusion (91.1±17.3 vs. 78.5±18.4 mm Hg, and 63.9±13.1 vs. 57.7±13.6 mm Hg, respectively), and after 15 minutes of reperfusion (102.2±16.8 vs. 88.1±14.4 mm Hg, and 67.7±10.7 vs. 62.5±10.4 mm Hg, respectively). We found a strong correlation between the differences of SAP and MAP and the dose of norepinephrine administered during the anhepatic phase (r=0.76 and r=0.77 for SAP and MAP, respectively), and after 5 minutes of reperfusion (r=0.71 and r=0.52 for SAP and MAP, respectively). The difference between central and peripheral BPs after 15 minutes of reperfusion mainly depended on the changes in the potassium concentration (r=0.55 for SAP and MAP) and base deficiency (r=0.73 and r=0.82 for SAP and MAP, respectively).Conclusion. Thus, it was proved that the invasive measurement of BP in the femoral artery is a more accurate method compared with that in the radial artery as it is less exposed to high doses of vasopressors and variations in the acid-base state during OLT

Inflammatory markers and infectious complications in the early postoperative period in orthotopic liver transplantation

Procalcitonin and c-reactive protein are routine inflammatary markers used in the perioperative period to detect surgical infectious complications. However, a number of studies have demonstrated that these laboratory markers appear less effective in identifying infectious complications in the early postoperative period in patients after liver transplantation, and their predictive power is limited. We hypothesized, that interleukin-6 could be a more reliable and precise marker of the development of infectious complications in this patient population

EVALUATION OF SYMPATHETIC BLOCKADE UNDER THORACIC EPIDURAL VERSUS BILATERAL PARAVERTEBRAL ANESTHESIAS DURING HIGH-TRAUMATICITY OPERATIONS ON THE UPPER ABDOMINAL ORGANS

Objective: to compare the degree of sympathetic blockade caused by thoracic epidural or bilateral paravertebral anesthesia. Superior mesenteric artery blood flow was measured calculating the coefficient of flow resistance (resistance index) as an indicator of the degree of sympathetic block in patients undergoing high-traumaticity operations on the upper abdominal organs under thoracic epidural or bilateral paravertebral anesthesia. The patients of both groups were noted to develop sympathetic blockade with a statistically significant reduction in vascular resistance (resistance index) of the superior mesenteric artery and with an increase in blood flow in the visceral bed. The degree of sympathetic blockade was statistically significantly higher in patients under epidural anesthesia. Conclusion. Bilateral thoracic paravertebral blockade decreases sympathetic nervous system activation and may be used during high-traumaticity surgery if there are existing or predictable contraindications to epidural anesthesia

CENTRAL PONTINE MYELINOLYSIS AFTER ORTHOTOPIC LIVER TRANSPLANTATION (TWO CASE REPORTS)

Central pontine myelinolysis (CPM) is the rare, but extremely severe complication after orthotopic liver trans- plantation. The reason for CPM is currently not precisely defined. However, the rapid correction of hyponatremia is considered as the main etiological factor. In this paper we present two clinical cases of CPM in patients under- went orthotopic liver transplantation. We also discuss the pathophysiology, epidemiology, clinical presentation, treatment options and preventive measures of CPM

The effect of using the algorithm of restrictive intraoperative fluid therapy, early immune enteral nutrition, and early patient mobilization on orthotopic liver transplantation outcomes

Major surgical procedures induce a number of pathophysiological responses, which may lead to a significant increase in perioperative complications, delayed recovery and rehabilitation, and longer hospital stays. Fast-track surgery, also known as enhanced recovery after surgery (ERAS) or as multimodal surgery, aims at decreasing the frequency of postoperative complications, creating optimal conditions for earlier postoperative recovery and return to normal life activities.The implementation of fast-track programs results in a reduced treatment duration without increase in readmissions. In this article, we have described our experience in the application of fast track program components to improve the outcomes after liver transplantation