Maria L. Bindi

Antifungal prophylaxis in liver transplant recipients: a randomized placebo‐controlled study

Abstract The aim of this study was to evaluate the efficacy of two antifungal prophylaxis regimens in liver transplant recipients. One hundred and twenty‐nine consecutive recipients were randomized to receive sequential treatment with intravenous liposomal amphotericin B + oral itraconazole, intravenous fluconazole + oral itraconazole, or intravenous and oral placebo. Frequency and incidence of mycotic colonization, local and systemic infection of mycotic origin, causes of death, and possible risk factors for mycotic infection were evaluated. The incidence of mycotic colonization was higher in the placebo group (P<0.01), but there was no significant difference in the incidence of infection between the three groups. Pre‐transplant colonization, severity of liver disease, and graft rejection were all risk factors for the development of fungal infection. The routine use of antifungal prophylaxis for all liver transplant recipients does not seem to be justified.

Fever, mental impairment, acute anemia, and renal failure in patient undergoing orthotopic liver transplantation: Posttransplantation malaria

A case of post‐transplant malaria is described. The patient presented fever and severe anemia after orthotopic liver transplantation. Diagnosis was made only after the review of donor characteristics. Although a high parasitemia was found at the moment of diagnosis, the treatment with quinine and doxycycline was successful. Donor epidemiology should always be considered for a prompt diagnosis of rare tropical diseases in the graft recipients. Liver Transpl 12:674–676, 2006.

Stress-inducing factors in ICUs: What liver transplant recipients experience and what caregivers perceive

The aim of this study was to compare a number of potentially stress‐generating factors related to an intensive care unit (ICU) stay from the points of view of patients undergoing liver transplantation or elective major abdominal surgery and their caregivers in order to identify differences and similarities that may help to optimize patient care. The ICU Environmental Stressor Scale questionnaire was administered to 104 liver transplant recipients, 103 major abdominal surgery patients, 35 nurses and 21 physicians. The ICU staff were asked to complete the questionnaire on the basis of their perception of patient stressors. Both patient groups identified Being unable to sleep, Being in pain, Having tubes in nose/mouth, Missing husband/wife, and Seeing family and friends only a few minutes a day as the major stressors; the healthcare providers correctly identified the most stressing factors for the patients, but gave them higher scores. The mean scores were 71.9 ± 18.7 for the transplant recipients, 66.3 ± 20.9 for the patients undergoing elective major abdominal surgery, 99.7 ± 19.2 for the nurses, and 92.7 ± 16.1 for the physicians (P < 0.001). The qualitative evaluations of potentially stress‐inducing ICU situations were substantially the same in the 2 patient groups, but the transplant recipients seemed to feel them more acutely. Although the caregivers identified the most discomforting situations, they overestimated the degree of stress they cause. The staff of each ICU should therefore seek to understand and reduce (even by means of simple interventions) the particular causes of psychophysical stress felt by their patients. (Liver Transpl 2005;11:967–972.)

Transcranial Doppler Sonography is Useful for the Decision-Making at the Point of Care in Patients with Acute Hepatic Failure: A Single Centre’s Experience

Acute hepatic failure (ALF) is an uncommon disease characterized by a rapid deterioration of the hepatic function with severe derangements of the mental status in previously healthy subjects due to massive hepatocytes necrosis. Neurological impairment, due to intracranial hypertension and cerebral ischemia, is a key factor because it is a main criterion to decide when to proceed to liver transplantation, which is only treatment for these patients. Therefore, neurological monitoring holds an essential role in the clinical management of ALF patients but it needs to be performed at the point-of-care in the majority of the cases as such critically ill patients cannot be moved away from the ICU because they frequently need continuous hemodynamic, ventilatory and renal support. We herein report and discuss our experience relating to the use of transcranial sonography as a neuro-monitoring tool in ALF patients. In our series this technique allowed a repeatable and reliable non-invasive assessment of cerebral blood flow changes at the bedside thus avoiding the complications associated with the use of an intracranial probe to measure intra-cranial pressure and making it possible to correctly evaluate the timing and feasibility of liver transplantation.

Early morbidity after pancreas transplantation

This study aims to evaluate and compare the early outcome of both pancreas‐alone transplantation (PTA) and simultaneous kidney–pancreas transplantation (SPKT) focusing on the complications affecting the first month after the procedures. The records of all patients who underwent PTA or SPKT were reviewed. We considered the length of ICU stay, the need for postoperative ventilatory support, hemodynamic and metabolic data (arterial pH, serum glucose, need for exogenous insulin), infectious diseases incidence, microbiological colonization rate and any kind of postoperative complication arising during the first month after the transplantation. PTA recipients underwent a quicker surgery (P < 0.01) with shorter ICU stay (P < 0.05) and a lower need for postoperative mechanical ventilation (P < 0.05). They also had a higher hemodynamic stability (P < 0.05) with less cardiological complications (P < 0.05) in the intra‐ and postoperative phases; bacterial colonisation was also less frequent in PTA recipients (P < 0.05). On the contrary, no significant difference was noted with regard to postoperative nausea/vomiting, sudden myocardial death, ICU re‐admissions, graft function, rate of rejection, grafts explantation and re‐transplantation. PTA could be considered as preemptive for severe diabetic complications in patients with long‐lasting severe type I diabetes. However, establishing the correct timing of PTA is of paramount importance in order not to expose the patients early to risks arising from a major surgery and heavy immunosuppressive treatments.

Octogenarian donors in liver transplantation grant an equivalent perioperative course to ideal young donors

BACKGROUND Use of grafts from very old donors for liver transplantation is controversial. AIM To compare the perioperative course of patients receiving liver grafts from young ideal vs octogenarian donors. METHODS Analysis of the perioperative course of patients receiving liver grafts from young, ideal (18-39 years) vs octogenarian (≥80years) deceased donors between 2001 and 2014. RESULTS 346 patients were studied: 179 (51.7%) received grafts aged 18-39 years whereas 167 (48.3%) received a graft from a donor aged ≥80years. Intra-operative cardiovascular (p=0.2), coagulopathy (p=0.5) and respiratory (p=1.0) complications and incidence of reperfusion syndrome (p=0.3) were similar. Patients receiving a young graft required more fresh frozen plasma units (p≤0.03) but did not differ for the need of packed red cells (p=0.2) and platelet (p=0.3) transfusions. Median ICU stay was identical (p=0.4). Patients receiving octogenarian vs young grafts did not differ in terms of death or re-transplant (p=1.0) during the ICU stay. Similar cardiovascular, respiratory, renal, infectious and neurological postoperative complication rates were observed in the two groups. CONCLUSIONS Octogenarian donors in liver transplantation grant an equivalent perioperative course to ideal young donors.

A Reliable and Handy “Rescue” Approach to Estimate Central Venous Pressure

Despite various criticisms, central venous pressure (CVP) continues to be used for the assessment of volume status in patients undergoing surgery or in the intensive care unit (ICU) [1]. Because peripheral venous pressure (PVP) reflects an ‘‘upstream’’ pressure that is coupled to CVP by a continuous blood column, it can be expected to have some correlation with CVP [2]. We measured PVP and CVP in 35 patients aged 34–78 years with primary or metastatic cancer consecutively undergoing major hepatic resection. Our aim was to test the response of PVP and CVP together with the reliability of their relationship during haemodynamic perturbations and portal vein cross-clamp. PVP and CVP values were respectively taken from a peripheral over-the needle catheter in a forearm vein and the distal port of a triple-lumen central venous catheter in the right internal jugular vein: these sites were not used for fluids administration. Venous pressures data pairs were recorded every 10 min during surgery and hourly, for 12 h, during spontaneous breathing in the ICU. A total of 883 PVP/CVP data pairs, 650 during surgery and 233 in the ICU, were collected and analyzed. The PVP/CVP recordings during times of haemodynamic instability (systolic blood pressure < 70 mmHg) and portal vein cross-clamp were extrapolated and evaluated separately. No clinical decision-making relevant to the patients management was made on the monitoring of the PVP The main findings of our study are given in the Table 1. In our experience, a peripheral catheter placed in a forearm vein recorded a pressure that reliably predicted the corresponding CVP measurement throughout the perioperative course of major liver surgery. A good correlation appeared even during haemodynamic instability. An important issue needing to be ruled out when PVP is taken in consideration for clinical purposes is whether it provides only a local information, limited to the peripheral venous system, or also has a systemic value. To this end it is necessary to consider that, as they are by definition always open during steady venous flow, valves in the peripheral venous system do not interrupt fluid continuity between the peripheral and central sites where pressures are measured [3]. However, to rule out factors possibly affecting PVP (extrinsic arm’s compression, hypertonia, shivering) it should be recorded only after the typical sinusoidal PVP trace appeared on the monitor indicating an un-interrupted Biancofiore G, Ostuni F, Bindi ML, Urbani L, Filipponi F. A reliable and handy ‘‘rescue’’ approach to estimate central venous pressure. J Clin Monit Comput 2008; 22:181–182

Pilot, open, randomized, prospective trial for normothermic machine perfusion evaluation in liver transplantation from older donors

Ex situ normothermic machine perfusion (NMP) might minimize ischemia/reperfusion injury (IRI) of liver grafts. In this study, 20 primary liver transplantation recipients of older grafts (≥70 years) were randomized 1:1 to NMP or cold storage (CS) groups. The primary study endpoint was to evaluate graft and patient survival at 6 months posttransplantation. The secondary endpoint was to evaluate liver and bile duct biopsies; IRI by means of peak transaminases within 7 days after surgery; and incidence of biliary complications at month 6. Liver and bile duct biopsies were collected at bench surgery, end of ex situ NMP, and end of transplant surgery. Interleukin (IL) 6, IL10, and tumor necrosis factor α (TNF‐α) perfusate concentrations were tested during NMP. All grafts were successfully transplanted. Median (interquartile range) posttransplant aspartate aminotransferase peak was 709 (371‐1575) IU/L for NMP and 574 (377‐1162) IU/L for CS (P = 0.597). There was 1 hepatic artery thrombosis in the NMP group and 1 death in the CS group. In NMP, we observed high TNF‐α perfusate levels, and these were inversely correlated with lactate (P < 0.001). Electron microscopy showed decreased mitochondrial volume density and steatosis and an increased volume density of autophagic vacuoles at the end of transplantation in NMP versus CS patients (P < 0.001). Use of NMP with older liver grafts is associated with histological evidence of reduced IRI, although the clinical benefit remains to be demonstrated.

The challenges of diagnosing thrombotic thrombocytopenic purpura in the critically ill. A case report

Thrombotic thrombocytopenic purpura (TTP) is associated with high mortality rates. TTP may have various and different presentations depending on the organs involved. It is now recognized to be the consequence of reduction of blood levels of the disintegrin and metalloprotease with thrombospondin motifs (ADAMTS)-13. Prompt diagnosis of TTP is paramount, because plasma exchange is the only treatment capable of improving patients survival with a dual mechanism: removal of anti-ADAMTS-13 auto-antibodies and infusion of the active protease available in the fresh frozen plasma. We report herein on the challenges in diagnosing TTP-like complications of post-surgical facial surgery in a young male patient.