Gaetano Burgio

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.

Successful Recanalization of a Complete Lobar Bronchial Stenosis in a Lung Transplant Patient Using a Combined Percutaneous and Bronchoscopic Approach

Abstract Airway stenosis is a major complication after lung transplantation that is usually managed with a combination of interventional endoscopic techniques, including endobronchial debridement, balloon dilation, and stent placement. Herein, we report a successful case of recanalization of a complete stenosis of the right middle lobe bronchus in a lung transplant patient, by using a combined percutaneous–bronchoscopic approach after the failure of endobronchial debridement.

Guillain-Barré syndrome after orthotopic liver transplantation: A clinical manifestation of immune reconstitution inflammatory syndrome?

Guillain-Barrè Syndrome, as part of the spectrum of dysimmune neuropathies, is unexpected to occur in immunocompromised hosts. We describe a clinical case of Guillain-Barrè syndrome, occurred a few weeks after a liver transplant, and we postulate that our case would satisfy all requirements to explain this peripheral nervous system complication as a clinical manifestation of an Immune reconstitution inflammatory syndrome. In this setting of liver transplantation, complicated by potentially multiple infective triggers, reduction of immunosuppression and reversal of pathogen-induced immunosuppression, through antimicrobial therapy, may have led to pro-inflammatory response. The pro-inflammatory pattern would have sustained the pathophysiologic mechanism of this immune neuropathy.

Central venous pressure monitoring via peripherally or centrally inserted central catheters: a systematic review and meta-analysis

Introduction The central venous pressure (CVP) is the most commonly used static marker of preload for guiding fluid therapy in critically ill patients, though its usefulness remains controversial. Centrally inserted central catheters (CICCs) are the gold-standard devices for CVP monitoring but peripherally inserted central catheters (PICCs) may represent a valid alternative. We undertook a systematic review and meta-analysis with the aim to investigate whether the difference between PICC- and CICC-measured CVP is not significant. Methods We searched for clinical studies published in PubMed and EMBASE databases from inception until December 21st 2016. We included studies providing data on paired and simultaneous CVP measurement from PICCs and CICCs. We conducted two analyses on the values of CVP, the first one according to the total number of CVP assessments, the second one considering the number of patients recruited. Results Four studies matched the inclusion criteria, but only three of them provided data for the meta-analyses. Both analyses showed non-significant differences between PICC-measured and CICC-measured CVP: 1489 paired simultaneous CVP assessments (MD 0.16, 95%CI −0.14, 0.45, p = 0.30) on a total of 57 patients (MD 0.22, 95%CI −1.46, 1.91, p = 0.80). Both analyses showed no heterogeneity (I2 = 0%). Conclusions Available evidence supports that CVP monitoring with PICCs is accurate and reproduces similar values to those obtained from CICCs. The possibility to monitor CVP should not be used among clinical criteria for preferring a CICC over a PICC line.

The importance of diastolic dysfunction in the development of weaning-induced pulmonary oedema

The group of Prof. Monnet et al. [1] elegantly described the characteristics of patients failing spontaneous breathing trials (SBTs; n = 128/283, 45%), confirming that a large proportion of weaning failures (59%) are associated with weaning-induced pulmonary oedema (WiPO). Three factors were independently associated with WiPO during SBT: chronic obstructive pulmonary disease, obesity and “structural cardiopathy”. However, we believe this study also deserves comment for the contribution of LV diastolic dysfunction (LVDD) in cases of WiPO. Despite patients with WiPO having similar LV ejection fraction to those without (61 versus 57%, p = 0.76), they had a higher E/E’ ratio (10.5 versus 8.8, p < 0.01), a parameter strongly associated with LVDD [2]. Furthermore, among patients with cardiac output (CO) monitoring in place during the SBT (n = 85/283), those developing WiPO showed a significant increase in global end-diastolic volume (~200 ml, +22% from baseline), while this parameter remained unchanged when WiPO did not occur. Interestingly, the vast majority of patients experiencing WiPO (n = 28/30) had preload-independence after a passive leg rising (PLR) test and, on the contrary, the PLR test showed preload-dependence in all the patients that did not experience WiPO (n = 55/55). The authors also reported that when preload-independence persisted despite fluid removal, most of the patients again showed WiPO on the following SBT, while a change to a preloaddependence condition was associated with a high rate of successful weaning. Taken together, such findings emphasize the importance of LVDD as a contributor to WiPO. The higher venous return during the shift from positive to negative pressure ventilation determines unfavourable LV loading conditions, which may be poorly tolerated in the context of LVDD. The importance of LVDD is not surprising since it has been associated with weaning failure [3, 4] and also with mortality in sepsis [5]. Of note, the authors report a higher incidence of septic-related cardiomyopathy in patients with WiPO (17 versus 2%, p = 0.01) [1]. We ask the authors to share their opinion on this aspect and to provide the E’ values comparing patients with or without WiPO, since the recently published guidelines have emphasized also the role of E’ when assessing LVDD [2]. On a separate note, another interesting finding that may deserve further comment is that patients with CO monitoring had a trend towards lower SBT failure (n = 45/85) compared to those with no CO monitoring (n = 83/198; p = 0.09, not reported). Was the CO monitoring intentionally used to keep the patient in a “safely dry” condition?

Liver Transplantation for Hemoperitoneum Secondary to Huge Multiple Hemangiomatosis: A Case Report of a Tele-intensive Care Unit in Deceased-Donor Management.

BACKGROUND Patients with growing and nonresectable liver hemangiomas should be followed up by a transplant center with extensive experience in complex liver disease. They could be treated on an emergency basis with orthotopic liver transplantation, with an expectation of good long-term results. MATERIALS AND METHODS We describe the case of a 37-year-old woman with liver hemangiomatosis followed up for 8 years, who presented with bleeding requiring transfusions and developed hemodynamic instability. We listed her for emergency transplant before her sisters living donor work-up could be completed. A liver from a cadaveric donor became available at a small local hospital with no experience in organ donation. Tele-intensive care unit (tele-ICU) technology was used for providing clinical data electronically to physicians, nurses, and other critical care specialists, creating medication orders, and communicating with on-site caregivers to implement changes in donor care. RESULTS The recipient was transplanted on an emergency basis with a specific customization and application of the telemedicine system in the management of the organ procurement by the recipient team. Tele-ICU technology was used for providing an effective intensive care unit service, managing and stabilizing the deceased donor and allowing the procurement to be carried out uneventfully. CONCLUSIONS Tele-ICU technology could be a promising resource for emergency transplantation, reducing the urgent need for a living donation and allowing prompt recipient team management of the deceased donor. Our first tele-ICU case offers early confirmation of the feasibility of the telemedicine system in deceased-donor management.