Antonio Arcadipane

Contribution of transjugular liver biopsy in patients with the clinical presentation of acute liver failure

PurposeAcute liver failure (ALF) treated with conservative therapy has a poor prognosis, although individual survival varies greatly. In these patients, the eligibility for liver transplantation must be quickly decided. The aim of this study was to assess the role of transjugular liver biopsy (TJLB) in the management of patients with the clinical presentation of ALF.MethodsSeventeen patients with the clinical presentation of ALF were referred to our institution during a 52 month period. A TJLB was performed using the Cook Quick-Core needle biopsy. Clinical data, procedural complications, and histologic findings were evaluated.ResultsCauses of ALF were virus hepatitis B infection in 7 patients, drug toxicity in 4, mushroom in 1, Wilson’s disease in 1, and unknown origin in 4. TJLB was technically successful in all patients without procedure-related complications. Tissue specimens were satisfactory for diagnosis in all cases. In 14 of 17 patients the initial clinical diagnosis was confirmed by TJLB; in 3 patients the initial diagnosis was altered by the presence of unknown cirrhosis. Seven patients with necrosis <60% were successfully treated with medical therapy; 6 patients with submassive or massive necrosis (≥85%) were treated with liver transplantation. Four patients died, 3 had cirrhosis, and 1 had submassive necrosis. There was a strict statistical correlation (r = 0.972, p < 0.0001) between the amount of necrosis at the frozen section examination and the necrosis found at routine histologic examination. The average time for TJLB and frozen section examination was 80 min.ConclusionIn patients with the clinical presentation of ALF, submassive or massive liver necrosis and cirrhosis are predictors of poor prognosis. TLJB using an automated device and frozen section examination can be a quick and effective tool in clinical decision-making, especially in deciding patient selection and the best timing for liver transplantation.

Impact of blood transfusion on early outcome of liver resection for colorectal hepatic metastases

The use of intra‐operative blood transfusion has been associated with worse surgical outcome in patients undergoing liver resection for malignancy.

Iatrogenic hypoglycemia secondary to tight glucose control is an independent determinant for mortality and cardiac morbidity

OBJECTIVE Evaluation of the effects of tight glycemia control in critically ill patients should include temporal as well as punctual glycemia data. METHODS Insulin drip was used to target intensive care unit (ICU) glucose levels between 80 and 126 mg dl⁻¹ in a consecutive series of adult cardiac surgery patients. ICU hourly glycemia was prospectively recorded. Glycemia standard deviation, hyperglycemia index (area under the curve for glycemia>126 mg dl⁻¹ divided by total hours in ICU), and hypoglycemic episodes were recorded and analyzed, together with outcomes. RESULTS A total of 596 patients were included. Hypoglycemia occurred in 21% of the patients. In-hospital mortality was 2.6%. There was a univariate correlation between mortality and glycemia standard deviation, and hypoglycemia occurrence. At multivariate analysis, hypoglycemia was a determinant for mortality (p=0.002; odds ratio (OR)=20.0), respiratory failure (p=0.0001; OR=1.4), requirement of a tracheostomy (p=0.0001; OR=21.6), and hemodynamic instability requiring intra-aortic balloon pump (IABP) (p=0.01; OR=1.5). To clarify the determinants of hypoglycemia, a second multivariate model was built. Diabetes (p=0.0001; OR=23) and chronic renal failure (p=0.01; OR=25) were the sole determinants for hypoglycemia occurrence. CONCLUSION Iatrogenic hypoglycemia secondary to ICU tight glycemia control correlates with hospital mortality, respiratory, and cardiac morbidity in patients undergoing cardiac surgery. ICU hyperglycemia index and glycemia temporal variability have no independent correlation with outcomes. Higher glycemia targets should be advised in the perioperative management of patients with diabetes and renal failure, as both conditions independently increase the risk of hypoglycemia occurrence.

Amiodarone or lidocaine for cardiac arrest: A systematic review and meta-analysis.

BACKGROUND Guidelines for treatment of out-of-hospital cardiac arrest (OOH-CA) with shockable rhythm recommend amiodarone, while lidocaine may be used if amiodarone is not available. Recent underpowered evidence suggests that amiodarone, lidocaine or placebo are equivalent with respect to survival at hospital discharge, but amiodarone and lidocaine showed higher hospital admission rates. We undertook a systematic review and meta-analysis to assess efficacy of amiodarone vs lidocaine vs placebo. METHODS We included studies published in PubMed and EMBASE databases from inception until May 15th, 2016. The primary outcomes were survival at hospital admission and discharge in OOH-CA patients enrolled in randomized clinical trials (RCT) according to resuscitation with amiodarone vs lidocaine vs placebo. If feasible, secondary analysis was performed including in the analysis also patients with in-hospital CA and data from non-RCT. RESULTS A total of seven findings were included in the metanalysis (three RCTs, 4 non-RCTs). Amiodarone was as beneficial as lidocaine for survival at hospital admission (primary analysis odds ratio-OR 0.86-1.23, p=0.40) and discharge (primary analysis OR 0.87-1.30, p=0.56; secondary analysis OR 0.86-1.27, p=0.67). As compared with placebo, survival at hospital admission was higher both for amiodarone (primary analysis OR 1.12-1.54, p<0.0001; secondary analysis OR 1.07-1.45, p<0.005) and lidocaine (secondary analysis only OR 1.14-1.58, p=0.0005). With regards to hospital discharge there were no differences between placebo and amiodarone (primary outcome OR 0.98-1.44, p=0.08; secondary outcome OR 0.92-1.33, p=0.28) or lidocaine (secondary outcome only OR 0.97-1.45, p=0.10). CONCLUSIONS Amiodarone and lidocaine equally improve survival at hospital admission as compared with placebo. However, neither amiodarone nor lidocaine improve long-term outcome.

The recipient with portal thrombosis and/or previous surgery.

INTRODUCTION Portal vein thrombosis (PVT) has been considered to be an absolute contraindication to liver transplantation (OLT) and previous upper abdominal surgery was considered to render it a high-risk procedure. Currently, these are only conditions considered risk factors increasing recipient morbidity and mortality. The objective of this study was to compare OLT perioperative morbidity, mortality, blood product consumption, and length of hospital stay among patients with or without PVT or with or without previous surgery. MATERIALS AND METHODS Among 366 OLTs performed between July 1999 and November 2007, 33 liver transplant recipients displayed previous PVT while 34 had undergone previous surgery. The two groups of marginal recipients were compared with a cohort of 33 patients without PVT or previous surgery. RESULTS The groups were homogeneous in terms of epidemiological variables, surgical techniques, and donor-related variables. In the PVT group, all analyzed parameters were the same as the control group; surgical time, anhepatic phase duration, early surgical complication, intensive care unit and hospital length of stay, and overall mortality. The only significant difference was the incidence of portal rethrombosis (P < .035). Among the previous surgery group, we did not observe significant differences. CONCLUSIONS PVT and previous surgery should no longer be considered contraindications for OLT.

Comparison of two different techniques of reperfusion in adult orthotopic liver transplantation

Abstract: The aim of this study was to determine the impact of two reperfusion techniques on the peri‐operative hemodynamic changes and early post‐operative graft function of adult patients undergoing orthotopic liver transplantation.

Nutritional aspects in patient undergoing liver resection.

In the past two decades, hepatic surgery has achieved important technical breakthroughs resulting in a drastic reduction of the onset of complications and in an improved post-resective survival. Pre-operative nutritional status is one of the key points for the success of a liver resection. Modern surgical achievement such as the development of living-related liver donation, and the possibility to perform more laparoscopic liver resection gave us the opportunity to extend post-operative protocol focused on early intestinal feeding to tumor patients. The aims of this review were to report the current status of the knowledge regarding nutritional aspects in liver resection patients.

Double carbapenem as a rescue strategy for the treatment of severe carbapenemase-producing Klebsiella pneumoniae infections: a two-center, matched case–control study

BackgroundRecent reports have suggested the efficacy of a double carbapenem (DC) combination, including ertapenem, for the treatment of carbapenem-resistant Klebsiella pneumoniae (CR-Kp) infections. We aimed to evaluate the clinical impact of such a regimen in critically ill patients.MethodsThis case–control (1:2), observational, two-center study involved critically ill adults with a microbiologically documented CR-Kp invasive infection treated with the DC regimen matched with those receiving a standard treatment (ST) (i.e., colistin, tigecycline, or gentamicin).ResultsThe primary end point was 28-day mortality. Secondary outcomes were clinical cure, microbiological eradication, duration of mechanical ventilation and of vasopressors, and 90-day mortality. Forty-eight patients treated with DC were matched with 96 controls. Occurrence of septic shock at infection and high procalcitonin levels were significantly more frequent in patients receiving DC treatment (p < 0.01). The 28-day mortality was significantly higher in patients receiving ST compared with the DC group (47.9% vs 29.2%, p = 0.04). Similarly, clinical cure and microbiological eradication were significantly higher when DC was used in patients infected with CR-Kp strains resistant to colistin (13/20 (65%) vs 10/32 (31.3%), p = 0.03 and 11/19 (57.9%) vs 7/27 (25.9%), p = 0.04, respectively). In the logistic regression and multivariate Cox-regression models, the DC regimen was associated with a reduction in 28-day mortality (OR 0.33, 95% CI 0.13–0.87 and OR 0.43, 95% CI 0.23–0.79, respectively).ConclusionsImproved 28-day mortality was associated with the DC regimen compared with ST for severe CR-Kp infections. A randomized trial is needed to confirm these observational results.Trial registrationClinicalTrials.gov NCT03094494. Registered 28 March 2017.

Veno-venous ECMO in ARDS after post-traumatic pneumonectomy

Dear Editor, Post-traumatic pneumonectomy is rare, but burdened by high mortality (50–80 %) and high morbidity, with a complication rate of [85 %, most commonly pneumonia and respiratory failure [1]. Life-threatening acute respiratory distress syndrome (ARDS) can develop, and the worst outcome is associated with right pneumonectomy [2]. Extracorporeal membrane oxygenation (ECMO) is a rescue option in ARDS that allows for protective mechanical ventilation and potentially less ventilator-induced damage [3]. In the past, trauma cases requiring anticoagulation for ECMO implantation posed a clinical dilemma that has now been partially overcome with the advent of latest generation devices. We report a case of multifactorial ARDS (pneumonia, polytransfusion, and fluid overload) after right pneumonectomy due to blunt chest trauma in which the patient was non-responsive to protective ventilation and conventional therapy [4]. The patient survived with early implantation and 29 days of ECMO support. A 25-year-old male (170 cm, 61 kg) was admitted to another facility with major blunt thoracic trauma causing right hemothorax, right main bronchial disruption, left pneumothorax, and pneumomediastinum. Surgical treatment consisted of right pneumonectomy, left chest drainage, and tracheostomy. Despite lung-protective ventilation, the patient developed ARDS, with hypoxic–hypercapnic respiratory failure [partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO2/FiO2) 40 at 36 h]. A PaO2/ FiO2 ratio of\100 with a FiO2 of 1.0 for more than 6 h indicates that a patient has a [80 % risk of death (Extracorporeal Life Support Organization guidelines) (Fig. 1). The referring center requested a consultation, and despite the recent trauma and surgery, we decided to start the patient on veno-venous ECMO (VV-ECMO) which achieved stabilization and allowed the patient to be safely transported about 200 km by helicopter to our institute. Vessel cannulation [18 Fr return (jugular) and 24 Fr drainage (femoral)] was performed after the administration of a heparin bolus (80 IU/kg). VVECMO support (miniaturized tip-totip heparin-coated circuit; Cardiohelp System; Maquet, Rastatt, Germany) was initiated, with the initial goal of achieving a blood flow of about 4 l/ min (3,000 rpm and 2 l/min of sweep gas flow) in order to provide maximal oxygenation support, but avoid iatrogenic alkalosis. Protective mechanical ventilation for transport was a FiO2 of 40 %, peak inspiratory pressure (PIP) of 20 cm H2O, positive end-expiratory pressure (PEEP) of 10 cm H2O, and respiratory rate (RR) of 10 breaths/min (Oxylog 3000 Plus; Draeger, Menlo Park, CA). On arrival at our institute, after a few hours of ECMO, gas exchange parameters were adequate (pH 7.34, PaO2 116 mmHg, PaCO2 58 mmHg). Microbiological screening revealed colonization by Acinetobacter baumannii (multi-drug resistant), which was confirmed by the swab test and bronchoalveolar lavage. Continuous heparin infusion was initiated to maintain an activated partial thromboplastin time of 40–50 s, and an

Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis

BackgroundPrevious studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan.MethodsWe performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion.ResultsSix RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p = 0.02), and a trend toward lower mechanical support, both overall (p = 0.07) and in patients with LVEF < 35% (p = 0.05).ConclusionsLevosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.