Ernesto A. Pretto

100 Multivisceral Transplants at a Single Center

Objective:The objective of this study was to summarize the evolution of multivisceral transplantation over a decade of experience and evaluate its current status. Summary Background Data:Multivisceral transplantation can be valuable for the treatment of patients with massive abdominal catastrophes. Its major limitations have been technical and rejection of the intestinal graft. Methods:This study consisted of an outcome analysis of 98 consecutive patients who received multivisceral transplantation at our institution. This represents the largest single center experience to date. Results:The most common diseases in our population before transplant were intestinal gastroschisis and intestinal dysmotility syndromes in children, and mesenteric thrombosis and trauma in adults. Kaplan Meier estimated patient and graft survivals for all cases were 65% and 63% at 1 year, 49% and 47% at 3 years, and 49% and 47% at 5 years. Factors that adversely influenced patient survival included transplant before 1998 (P = 0.01), being hospitalized at the time of transplant (P = 0.05), and being a child who received Campath-1H induction (P = 0.03). Among 37 patients who had none of these 3 factors (15 adults and 22 children), estimated 1- and 3-year survivals were 89% and 71%, respectively. Patients transplanted since 2001 had significantly less moderate and severe rejections (31.6% vs 67.6%, P = 0.0005) with almost half of these patients never developing rejection. Conclusions:Multivisceral transplantation is now an effective treatment of patients with complex abdominal pathology. The incidences of serious acute rejection and patient survival have improved in the most recent experience. Our results show that the multivisceral graft seems to facilitate engraftment of transplanted organs and raises the possibility that there is a degree of immunologic protection afforded by this procedure.

An analysis of prehospital mortality in an earthquake. Disaster Reanimatology Study Group.

INTRODUCTION Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy. METHODS A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991. RESULTS Fifty-four deaths occurred prior to hospitalization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p < .01) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death. CONCLUSIONS A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life-saving potential in these events.

Cardiopulmonary bypass after prolonged cardiac arrest in dogs

Ventricular fibrillation (VF) cardiac arrest of more than ten minutes can be survived by cerebral neurons, but restoration of spontaneous circulation (ROSC) by external CPR is unreliable. Cardiopulmonary bypass (CPB) permits control of pressure, flow, oxygenation, temperature, and composition of blood. After 12 1/2 minutes of normothermic VF cardiac arrest, CPB was used as a research tool for reperfusion and assisted circulation for two hours in ten dogs without thoracotomy, with plasma substitute priming, and without preceding CPR (a deliberately nonclinical scenario). Recovery was compared with that in ten control dogs in which standard CPR with advanced life support (ALS) for up to 30 minutes was used to achieve ROSC. Both groups subsequently had blood pressure, blood gases, ventilation, and other parameters controlled for 20 hours, and intensive therapy to 72 hours. CPB achieved ROSC more successfully (ten of ten vs six of ten controls) (P less than .05), and more rapidly, with fewer defibrillation attempts and with less epinephrine (P less than .05). CPB improved 72-hour survival (seven of ten vs two of ten controls) (P = .025). Between two and 24 hours, of those with ROSC, intractable cardiogenic shock killed four of six control dogs (NS). CPB was followed by fewer arrhythmias. CPB increased recovery of consciousness (five of ten CPB vs zero of six controls with ROSC) (P = .037), but achieved neurologic normality in only one of ten. Cardiac arrest and CPB (without CPR) resulted in less myocardial morphologic damage than did standard CPR (P less than .025).(ABSTRACT TRUNCATED AT 250 WORDS)

Disaster reanimatology potentials : A structured interview study in Armenia : I. Methodology and preliminary results

In general, preparations for disasters which result in mass casualties do not incorporate a modern resuscitation approach. We explored the life-saving potential of, and time limits for life-supporting first aid (LSFA), advanced trauma life support (ATLS), resuscitative surgery, and prolonged life support (PLS: intensive care) following the earthquake in Armenia on 7 December 1988. We used a structured, retrospective interview method applied previously to evaluation of emergency medical services (EMS) in the United States. A total of 120 survivors of, and participants in the earthquake in Armenia were interviewed on site (49 lay eyewitnesses, 20 search-rescue personnel, 39 medical personnel and records, and 12 administrators). Answers were verified by crosschecks. Preliminary results permit the following generalizations: 1) a significant number of victims died slowly as the result of injuries such as external hemorrhage, head injury with coma, shock, or crush syndrome; 2) early search and rescue was performed primarily by uninjured covictims using hand tools; 3) many lives potentially could have been saved by the use of LSFA and ATLS started during extrication of crushed victims. 4) medical teams from neighboring EMS systems started to arrive at the site at 2-3 hours and therefore, A TLS could have been provided in time to save lives and limbs; 5) some amputations had to be performed in the field to enable extrication; 6) the usefulness of other resuscitative surgery in the field needs to be clarified; 7) evacuations were rapid; 8) air evacuation proved essential; 9) hospital intensive care was well organized; and 10) international medical aid, which arrived after 48 hours, was too late to impact on resuscitation. Definitive analysis of data in the near future will lead to recommendations for local, regional, and National Disaster Medical Systems (NDMS).

Disaster Reanimatology Potentials: A Structured Interview Study in Armenia. III. Results, Conclusions, and Recommendations

National medical responses to catastrophic disasters have failed to incorporate a resuscitation component. Purpose: This study sought to determine the lifesaving potentials of modern resuscitation medicine as applied to a catastrophic disaster situation. Previous articles reported the preliminary results (I), and methodology (II) of a structured, retrospective interview study of the 1988 earthquake in Armenia. The present article (III) reports and discusses the definitive findings, formulates conclusions, and puts forth recommendations for future responses to catastrophic disasters anywhere in the world. Results: Observations include: 1) The lack of adequate construction materials and procedures in the Armenian region contributed significantly to injury and loss of life; 2) The uninjured, lay population together with medical teams including physicians in Armenia were capable of rapid response (within two hours); 3) Due to a lack of Advanced Trauma Life Support (ATLS) training for medical teams and of basic first-aid training of the lay public, and scarcity of supplies and equipment for extrication of casualties, they were unable to do much at the scene. As a result, an undetermined number of severely injured earthquake victims in Armenia died slowly without the benefit of appropriate and feasible resuscitation attempts. Recommendations: 1) Widespread adoption of seismic-resistant building codes for regions of high seismic risk; 2) The lay public living in these regions should be trained in life-supporting first-aid (LSFA) and basic rescue techniques; 3) Community-wide emergency medical services (EMS) systems should be developed world-wide (tai-lored to the emergency needs of each region) with ATLS capability for field resuscitation; 4) Such systems be prepared to extend coverage to mass casualties; 5) National disaster medical system (NDMS) plans should provide integration of existing trauma-EMS systems into regional systems linked with advanced (heavy) rescue (public works, fire, police); and 6) New techniques and devices for victim extrication should be developed to enable rapid extrication of earthquake casualties within 24 hours.

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.

Surgery under extreme conditions in the aftermath of the 2010 haiti earthquake: The importance of regional anesthesia

The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations were performed with local anesthesia. Because of these austere conditions, an anesthesiologist, experienced and equipped to administer regional block anesthesia, was dispatched three days later to perform anesthesia for limb amputations, debridements, and wound care using single shot block anesthesia until a better equipped tent facility was established. After four weeks, the relief effort evolved into a 250-bed, multi-specialty trauma/intensive care center staffed with >200 medical, nursing, and administrative staff. Within that timeframe, the facility and its staff completed 1,000 surgeries, including spine and pediatric neurological procedures, without major complications. This experience suggests that when local emergency medical resources are completely destroyed or seriously disabled, a surgical team staffed and equipped to provide regional nerve block anesthesia and acute pain management can be dispatched rapidly to serve as a bridge to more advanced field surgical and intensive care, which takes longer to deploy and set up.

Hospital disaster preparedness in Osaka, Japan

PURPOSE To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area. METHODS Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self-sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals. RESULTS A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply. CONCLUSIONS No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans.

Reappraisal of Mouth-to-Mouth Ventilation During Bystander-Initiated CPR

To the Editor: The “reappraisal” of the literature on mouth-to-mouth ventilation during bystander-initiated CPR, by a working group of the Basic Life Support and Pediatric Life Support subcommittees of the American Heart Association (AHA),1 is misleading and incomplete. There is no convincing evidence that the low incidence of initiation of CPR out of hospital by lay bystanders is the result of fear of becoming infected by mouth-to-mouth ventilation. Such fear should not be promoted. If such fear exists, however, it should be mitigated by explaining that initiating CPR is safe and by carrying a pocket-size barrier for ventilation of strangers. The errors in this article concerning behavioral, educational, epidemiological, and logistics issues will be summarized in a separate letter by Braslow and Brennan. Although the article says “… it is not intended to change any current AHA recommendations,” its publication has created confusion and the erroneous impression for laypersons and the media that in sudden coma, bystanders will save lives by merely pushing on the sternum (step C, circulation support). In cardiac arrest, oxygenated blood must be circulated to restore heartbeat and to keep the brain viable, requiring “head tilt plus blowing plus pumping.” The article suggests that mouth-to-mouth ventilation can be omitted in various forms of sudden loss of consciousness.1 Laypersons cannot differentiate between various forms of sudden coma and between the absence versus presence of a weak pulse. Coma always results in upper airway obstruction if the neck is flexed (references 26 to 31 in the article by Becker et al),2 3 4 5 6 as experienced by anesthesiologists every day. There are 20 million general anesthesias given in the United States each year. The data in Figure 1 are misleading1 because Gordon’s measurements of 1950 (reference 24 in the article by Becker et …

Liver retransplantation of more than two grafts for recurrent failure.

Background. Transplantation of more than two livers for recurring graft failure has not been specifically addressed in the literature. Methods. A retrospective analysis was conducted from a total of 2527 overall liver transplants at our institution. Main indications for multiple retransplant included primary nonfunction, chronic rejection, hepatic artery thrombosis, and recurrent disease. Results. We identified 39 patients who received more than two grafts (32 received 3 grafts, 5 received 4 grafts, and 2 received 5 grafts). All patients required interposition arterial grafts from the aorta and hepatojejunostomy for the biliary reconstruction. Seventeen patients are still alive at last follow-up. Perioperative mortality rates after 3rd, 4th, and 5th liver graft were 25%, 14%, and 50%, respectively. Patient and graft survival rates were 72% and 56% at 1 year, respectively. Median length of stay was 27 days and median graft survival was 2.9 years. Conclusions. Selection of patients and a significant use of available resources are some of the important factors that clinicians need to take into account when dealing with multiple retransplantations. With such conditions, however, liver retransplantation of more than two grafts can be a life-saving procedure.