A. Kaba

Epidural Levobupivacaine 0.1% or Ropivacaine 0.1% Combined with Morphine Provides Comparable Analgesia After Abdominal Surgery

Ropivacaine appears attractive for epidural analgesia because it produces less motor block than racemic bupivacaine. The potential benefits of levobupivacaine with regard to motor blockade require further investigations. In this study, we compared the efficacy, dose requirements, side effects, and motor block observed with epidural levobupivacaine and ropivacaine when given in combination with small-dose morphine for 60 h after major abdominal surgery. Postoperatively, 50 patients were randomly allocated, in a double-blinded manner, to patient-controlled epidural analgesia with the same settings and without basal infusion, using 0.1% levobupivacaine or 0.1% ropivacaine. Both were combined with an epidural infusion of 0.1 mg/h morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores measured on a 100-mm visual analog scale were approximately 20 mm at rest and 40 mm during mobilization in both groups. Bromage scores were 1 for all patients after the fourth postoperative hour. Consumption of levobupivacaine and ropivacaine were similar: 344 ± 178 mg levobupivacaine versus 347 ± 199 mg ropivacaine 48 h postoperatively. On postoperative day 2, 19 patients in the ropivacaine group versus 12 in the levobupivacaine group were able to ambulate (P < 0.05). No difference was noted concerning incidence of side effects. We conclude that when used as patient-controlled epidural analgesia and combined with small-dose epidural morphine, 0.1% levobupivacaine and 0.1% ropivacaine produce comparable postoperative analgesia with a similar incidence of side effects.

Liver transplant donation after cardiac death : experience at the University of Liège

OBJECTIVE Donation after cardiac death (DCD) has been proposed to overcome in part the organ donor shortage. In liver transplantation, the additional warm ischemia time associated with DCD procurement may promote higher rates of primary nonfunction and ischemic biliary lesions. We reviewed the results of liver transplantation from DCD. PATIENTS AND METHODS From 2003 to 2007, we consecutively performed 13 controlled DCD liver transplantations. The medical records of all donors and recipients were retrospectively reviewed, evaluating in particular the outcome and occurrence of biliary complications. Mean follow-up was 25 months. RESULTS Mean donor age was 51 years, and mean intensive care unit stay was 5.4 days. Mean time between ventilation arrest and cardiac arrest was 9.3 minutes. Mean time between cardiac arrest and arterial flushing was 7.7 minutes. No-touch period was 2 to 5 minutes. Mean graft cold ischemia time was 295 minutes, and mean suture warm ischemia time was 38 minutes. Postoperatively, there was no primary nonfunction. Mean peak transaminase level was 2546 UI/mL. Patient and graft survival was 100% at 1 year. Two of 13 patients (15%) developed main bile duct stenosis and underwent endoscopic management of the graft. No patient developed symptomatic intrahepatic bile duct strictures or needed a second transplantation. CONCLUSIONS Our experience confirms that controlled DCD donors may be a valuable source of transplantable liver grafts in cases of short warm ischemia at procurement and minimal cold ischemia time.

End of life care in the operating room for non-heart-beating donors: organization at the University Hospital of Liège.

Non-heart-beating (NHB) organ donation has become an alternative source to increase organ supply for transplantation. A NHB donation program was implemented in our institution in 2002. As in many institutions the end of life care of the NHB donor (NHBD) is terminated in the operating room (OR) to reduce warm ischemia time. Herein we have described the organization of end of life care for these patients in our institution, including the problems addressed, the solution proposed, and the remaining issues. Emphasis is given to our protocol elaborated with the different contributors of the chain of the NHB donation program. This protocol specifies the information mandatory in the medical records, the end of life care procedure, the determination of death, and the issue of organ preservation measures before NHBD death. The persisting malaise associated with NHB donation reported by OR nurses is finally documented using an anonymous questionnaire.

Contribution of Donors After Cardiac Death to the Deceased Donor Pool: 2002 to 2009 University of Liege Experience

OBJECTIVE In this study, we have evaluated the organ procurement and transplantation activity from donors after cardiac death (DCD) at our institution over an 8-year period. Our aim was to determine whether this program influenced transplantation programs, or donation after brain death (DBD) activity. METHODS We prospectively collected our procurement and transplantation statistics in a database for retrospective review. RESULTS We observed an increasing trend in potential and actual DCD number. The mean conversion rate turning potential into effective donors was 58.1%. DCD accounted for 16.6% of the deceased donor (DD) pool over 8 years. The mean age for effective DCD donors was 53.9 years (range, 3-79). Among the effective donors, 63.3% (n = 31) came from the transplant center and 36.7% (n = 18) were referred from collaborative hospitals. All donors were Maastricht III category. The number of kidney and liver transplants using DCD sources tended to increase. DCD kidney transplants represented 10.8% of the DD kidney pool and DCD liver transplants made up 13.9% of the DD liver pool over 8 years. The DBD program activity increased in the same time period. In 2009, 17 DCD and 33 DBD procurements were performed in a region with a little >1 million inhabitants. CONCLUSION The establishment of a DCD program in our institution enlarged the donor pool and did not compromise the development of the DBD program. In our experience, DCD are a valuable source for abdominal organ transplantation.

A More Than 20% Increase in Deceased-Donor Organ Procurement and Transplantation Activity After the Use of Donation After Circulatory Death

BACKGROUND Organ procurement and transplant activity from controlled donation after circulatory death (DCD) was evaluated over an 11-year period to determine whether this program influenced the transplant and donation after brain death (DBD) activities. MATERIAL AND METHODS Deceased donor (DD) procurement and transplant data were prospectively collected in a local database for retrospective review. RESULTS There was an increasing trend in the potential and actual DCD numbers over time. DCD accounted for 21.9% of the DD pool over 11 years, representing 23.7% and 24.2% of the DD kidney and liver pool, respectively. The DBD retrieval and transplant activity increased during the same time period. Mean conversion rate turning potential into effective DCD donors was 47.3%. Mean DCD donor age was 54.6 years (range, 3-83). Donors ≥60 years old made up 44.1% of the DCD pool. Among referred donors, reasons for nondonation were medical contraindications (33.7%) and family refusals (19%). Mean organ yield per DCD donor was 2.3 organs. Mean total procurement warm ischemia time was 19.5 minutes (range, 6-39). In 2012, 17 DCD and 37 DBD procurements were performed in the Liege region, which has slightly >1 million inhabitants. CONCLUSIONS This DCD program implementation enlarged the DD pool and did not compromise the development of DBD programs. The potential DCD pool might be underused and seems to be a valuable organ donor source.

Living related liver transplantation in adults: first year experience at the University of Liège.

Abstract Living related liver transplantation (LRLT) in adult recipients has been recently developed to overcome the organ donor shortage, but LRLT leaves the healthy donors at risk of serious post-operative complications, or even death. The aim of this paper is to report the prospective evaluation of the initial experience of adult LRLT at the University of Liège. From March 2002 till March 2003, in a consecutive series of 35 adult liver transplantations, five recipients (mean age: 51 years) underwent LRLT, including one retransplantation. Indications for transplantation were autoimmune hepatitis, hepatitis B virus related cirrhosis with hepatocarcinoma (two cases), hepatitis C virus related cirrhosis with hepatocarcinoma, and ischemic intrahepatic bile duct necrosis 10 years after primary liver transplantation. Mean age of the donors was 34 years (range: 21-53 years). All donation cases were intra familial at first degree. The right lobe was used as a graft in four cases and the left lobe in one case. All right lobe donors developed transient hyperbilirubinemia and hypocoagulation for 4 to 6 days. No severe complication (transfusion, bile duct fistula, reintervention, rehospital-ization) nor significant long-term sequelae were observed in the donors. In the recipients, graft function was immediate, and there was no small-for-size syndrome. One recipient developed biliary fistula treated by reoperation. One recipient died from invasive aspergillosis 11 days after the procedure. The four other recipients were alive without recurrence of the disease at follow-up. This report confirmed that LRLT may be a valuable alternative to cadaveric liver transplantation in the era of organ donor shortage. However, even if there was no severe complication for the donors in our preliminary experience, LRLT puts healthy living donors at risk of significant morbidity and even death.

Effect of the transversus abdominis plane block on pain after laparoscopic inguinal hernia repair: 8AP5–5

Background and Goal of Study: The transversus abdominis plane (TAP) block is a new locoregional analgesia technique proposed to treat pain after abdominal surgery.1-3 We investigated the effect of TAP block on pain after laparoscopic inguinal hernia repair. Materials and Methods: With IEC approval and informed consent, 30 patients scheduled for preperitoneal laparoscopic inguinal hernia repair were included in this randomized double blind study. General anaesthesia (sevoflurane in O2:air) was used in all patients. After the induction of anaesthesia patients were randomly allocated in two groups (n=15 in each group): TAP block using McDonnell’s technique1 with 20 ml of levobupivacaine (LEVO) 0.375% Adr 1/200000 75 μg clonidine at each side or 20 ml saline (SAL) Adr 1/200000 75 μg clonidine at each side. Postoperative analgesia was standardized: iv piritramide titration the first h in the recovery room, then paracetamol 1 g/6 h and diclofenac 75 mg/12 h if necessary. Pain scores (100 mm VAS) at rest and during mobilisation during the first two postoperative days, consumption of piritramide, paracetamol, and time to first paracetamol request were recorded. Data (mean±SD) were analyzed by ANOVA, or Student t-test; P < 0.05 = statistically significant. Results and Discussion: All analgesic parameters were better in the LEVO group, but differences between groups did not reach statistical significance: pain scores at rest (Table) were lower (P = 0.1), piritramide consumption was less (1,7 ± 0.6 mg vs. 3.6 ± 0.9 mg, P = 0.1), and time to first paracetamol request was longer (11 ± 13 h vs. 7 ± 12 h, P = 0.1) in the LEVO group as compared the SAL group.

Effects of intravenous clonidine on postoperative analgesia, sedation, and haemodynamic in morbidly obese patients undergoing laparoscopic gastric by-pass: 14AP4–10

Background and Goal of Study: Pelvic trauma followed by reconstructive surgery is associated with a high incidence of nerve damage and pain. The NMDA antagonist ketamine is not only effective in managing the symptoms of neuropathic pain [1] but is also morphine sparing in the first 24 hours after surgery [2]. We report on the use of patient controlled analgesia (PCA) morphine combined with ketamine for this patient group. Materials and Methods: We followed 132 in-patients who underwent reconstructive surgery for pelvic fractures; 59 received PCA morphine-plus-ketamine, both drugs 1mg/ml (1ml bolus; 5 minute lockout) for postoperative pain relief (Treatment group; TG), 73 historically matched patients received PCA morphine alone, same prescription (Control group; CG). Record was kept of patients’ demographic details, length of time and total morphine dose using PCA, effectiveness of pain control, side effects and number of Acute Pain Team contacts. The incidence, character and treatment of persistent post-PCA pain as well as overall patient experience was also recorded. Results and Discussion: Demographic details were similar in both groups. No statistically significant differences were observed between TG and CG with respect to duration and total morphine dose using PCA, effectiveness of pain control and patient experience, even when age or sex were investigated as confounders. Pruritus was commoner in CG 8% (6/73) compared with TG 3% (2/59) but the difference was not significant. Persistent post-PCA pain whilst in hospital was reported by 19% (14/73) patients in CG and was classified as neuropathic in 64% (9/14) of these patients, whilst 7% (4/59) patients in TG reported persistent post-PCA pain, none of whom were classified as having neuropathic pain. These differences did not achieve statistical significance. Conclusion(s): PCA morphine-plus-ketamine provided comparable analgesia to PCA morphine alone following reconstructive surgery for pelvic trauma without any increase in side effects. There was a trend towards a reduced in-hospital incidence of persistent postoperative neuropathic pain following PCA morphine-plus-ketamine but longer term follow up is needed. References: 1 Schmid R. Use and efficacy of low-dose ketamine in the management of acute postoperative pain: a review of current techniques and outcomes Pain 1999; 82: 111-125. 2 Bell RF, Dahl JB, Moore RA, Kalso E. Peri-operative ketamine for acute post-operative pain: a quantitative and qualitative systematic review (Cochrane review). Acta Anaesthesiologica Scandinavica 2005; 49: 1405-1428.

[150] CADAVERIC WHOLE LIVER TRANSPLANTATION FOR NON-ACETAMINOPHEN FULMINANT HEPATIC FAILURE: A 20-YEAR EXPERIENCE

AIM: To investigate the long-term results of liver transplantation (LT) for non-acetaminophen fulminant hepatic failure (FHF). METHODS: Over a 20-year period, 29 FHF patients underwent cadaveric whole LT. Most frequent causes of FHF were hepatitis B virus and drug-related (not acetaminophen) liver failure. All surviving patients were regularly controlled at the out-patient clinic and none was lost to follow-up. Mean follow-up was 101 mo. RESULTS: One month, one-, fi ve- and ten-year patient survival was 79%, 72%, 68% and 68%, respectively. One month, one-, fi ve- and ten-year graft survival was 69%, 65%, 51% and 38%, respectively. Six patients needed early (< 2 mo) retransplantation, four for primary non-function, one for early acute refractory rejection because of ABO blood group incompatibility, and one for a malignant tumor found in the donor. Two patients with hepatitis B FHF developed cerebral lesions peri-transplantion: one developed irreversible and extensive brain damage leading to death, and one suffered from deep defi cits leading to continuous medical care in a specialized institution.

Perioperative hyperglycaemia is similar in nondiabetic morbidly obese and nonobese patients undergoing prolonged laparoscopy: 1AP3-4

Anesthesia and Intensive Care Medicine, CHU Liège, Liège, Belgium Background and Goal of Study: Surgical stress results in perioperative hyperglycemia.1 Insuline resistance frequently develops in morbidly obese patients.2 We tested the hypothesis that perioperative hyperglycemia is greater in nondiabetic obese patients than in nonobese patients. Materials and Methods: After IRB approval, 30 ASA I-III nondiabetic (normal HbA1c and fasting glycemia) morbidly obese patients (BMI: 43.1 7.9 kg/m2) scheduled for laparoscopic gastric bypass were compared to 20 nondiabetic nonobese patients (BMI: 26.4 3.1 kg/m2) scheduled for laparoscopic colectomy. Anesthetic technique (sevoflurane in O2:air) was standardized in all patients. After surgery, all patients were administered Glucose 10%. 80 ml/h. Blood glucose was measured before premedication, at induction of anesthesia, after tracheal intubation, every 30 min intraop, and then every 6 h postop for 24 h. Data (mean SD) were analyzed using Students’ t test or ANOVA for repeated measures when appropriate; P 0.05 statistically significant. Results and Discussions: HbA1c plasma concentrations were similar in nonobese (5.5 0.5%) and obese (5.6 0.6%) patients. Intraand postop glycemia were not significantly different in morbidly obese and nonobese patients (Fi.).