R. Scherer

Incidence of neurologic complications related to thoracic epidural catheterization.

BackgroundDue to potential neurologic sequelae, the risk:benefit ratio of thoracic epidural analgesia is controversial. Surprisingly, however, few available data address neurologic complications. The incidence of neurologic complications occurring after thoracic epidural catheterization was studied

Comparison of histidine-tryptophan-ketoglutarate (HTK) solution versus University of Wisconsin (UW) solution for organ preservation in human liver transplantation

Over a 30-month period, 60 patients (30 in each group) suffering from end-stage liver disease or primary hepatic malignancy and scheduled for liver transplantation were enrolled in a prospective, randomized study to compare two methods of liver preservation: histidinetryptophan-ketoglutarate (HTK) solution versus University of Wisconsin (UW) solution. Entry criteria for both groups were: age (18–65 years), elective surgery (transplantable or urgent category of the recipients), first transplantations and harvesting procedure performed by the same team. The parameters under investigation were the clinical and laboratory data preand post-transplantation, as well as follow-up data such as complications and survival. There were no significant differences in the two groups as far as the evaluation criteria were concerned, even when cold ischemia time was more than 15h (n=7). A slight, yet not significant, increase in late complications of the biliary anastomoses could be seen in the UW group. Hepatocellular injury (SGOT, SGPT, GLDH, lactate) appeared to be more marked in the HTK group. These results suggest that both HTK and UW solutions are appropriate for clinical use in liver transplantation, even if cold ischemia time is more than 15h.

Comparison of histidine-tryptophan-ketoglutarate (HTK) solution versus University of Wisconsin (UW) solution for organ preservation in human liver transplantation. A prospective, randomized study.

Abstract Over a 30‐month period, 60 patients (30 in each group) suffering from end‐stage liver disease or primary hepatic malignancy and scheduled for liver transplantation were enrolled in a prospective, randomized study to compare two methods of liver preservation: histidine‐tryptophan‐ketoglutarate (HTK) solution versus University of Wisconsin (UW) solution. Entry criteria for both groups were: age (18–65 years), elective surgery (transplantable or urgent category of the recipients), first transplantations and harvesting procedure performed by the same team. The parameters under investigation were the clinical and laboratory data pre‐and post‐transplantation, as well as follow‐up data such as complications and survival. There were no significant differences in the two groups as far as the evaluation criteria were concerned, even when cold ischemia time was more than 15 h (n= 7). A slight, yet not significant, increase in late complications of the biliary anastomoses could be seen in the UW group. Hepatocellular injury (SGOT, SGPT, GLDH, lactate) appeared to be more marked in the HTK group. These results suggest that both HTK and UW solutions are appropriate for clinical use in liver transplantation, even if cold ischemia time is more than 15 h.

Combined antithrombin III and C1-esterase inhibitor treatment decreases intravascular fibrin deposition and attenuates cardiorespiratory impairment in rabbits exposed to Escherichia coli endotoxin.

OBJECTIVE To assess the effect of a combined antithrombin III and C1-esterase inhibitor treatment on intravascular organ fibrin deposition and cardiorespiratory changes following intravenous Escherichia coli endotoxin (lipopolysaccharide [LPS] 80 microg/kg i.v.) exposure. DESIGN Prospective, randomized trial. SETTING Research laboratory of a university medical center. SUBJECTS Anesthetized, instrumented and mechanically ventilated rabbits ([Chbb:CH); n = 40). INTERVENTIONS Endotoxin was given to 30 animals. Ten animals received no inhibitor (endotoxin control group). The other animals were either treated by high-dose (300 units/kg; n = 10) or low-dose (100 units/kg; n = 10) combined antithrombin III and C1-esterase inhibitor administration. Ten rabbits (time control group) were given placebo (sodium chloride 0.9%). Cardiorespiratory variables were assessed at baseline, 120 mins, and 240 mins after endotoxin or placebo administration. Four hours after endotoxin injection, liver, lung, and kidney tissue samples were examined for intravascular fibrin deposition by light microscopy. MEASUREMENTS AND MAIN RESULTS Inhibitor treatment significantly decreased clot formation in lungs and livers without, however, demonstrating a clear dose-dependent effect. Combined antithrombin III/C1-esterase treatment attenuated the decrease of mean arterial pressure and cardiac output observed following endotoxin injection. Blood pressure improvement was significantly dependent on dosage administered. CONCLUSION Combination of antithrombin III and C1-esterase inhibitor treatment during early endotoxin shock decreased organ fibrin deposition and improved cardiovascular stability.

Hemodynamic changes after retroperitoneal CO2 insufflation for posterior retroperitoneoscopic adrenalectomy.

Intraoperative complications and hemodynamic alterations during posterior capnoretroperitoneoscopic adrenalectomy in the prone position were investigated in 16 consecutive patients using invasive hemodynamic monitoring.Under general anesthesia with propofol and fentanyl, hemodynamic changes were made before (M1) and during retroperitoneal CO2 insufflation (15 mm Hg) [M2]; 20 mm Hg [M3]. Retroperitoneal insufflation resulted in a significant increase of cardiac output (+72%), stroke volume (+42%), mean arterial pressure (+39%), and mean pulmonary arterial pressure (+36%). Although retroperitoneal inflation was accompanied by a significant increase of central venous pressure (+37%), an increase of preload may have led to higher filling pressures. Heart rate, systemic vascular resistance, and pulmonary vascular resistance did not show significant changes. One pneumothorax and two cutaneous emphysemas occurred. We have demonstrated, in a small number of patients, that retroperitoneal CO2 insufflation for posterior capnoretroperitoneoscopic adrenalectomy in the prone position results in hemodynamic changes without apparent adverse effects. (Anesth Analg 1996;82:827-31)

Influence of heparin and hirudin on endothelial binding of antithrombin in experimental thrombinemia.

ObjectiveDuring the last decade, experimental and clinical evidence has accumulated that antithrombin (AT) exerts anti-inflammatory effects when given in high doses. Meanwhile, AT substitution has been shown to significantly increase prostacyclin release. However, the link between endothelial AT binding and anti-inflammatory AT effects remains to be established in vivo, although heparin has been shown to counteract anti-inflammatory AT effects. We hypothesized that the administration of heparin in endotoxin-challenged rats would decrease endothelial AT binding and systemic prostacyclin concentrations. DesignProspective, randomized, controlled experimental in vivo study. SettingResearch laboratory of a university hospital. AnimalsFifty-six Wistar rats. InterventionsBaseline values of coagulation variables were measured in six animals. Forty of 50 Wistar rats in the study groups were given endotoxin (50 mg·kg−1 iv) and were treated with saline (group LPS), AT (15 units·kg−1·hr−1) (LPS+AT), AT and heparin (80 IU·kg−1·hr−1), or AT and hirudin (0.12 mg·kg−1 · hr−1); the other 10 received saline instead of endotoxin and were treated with AT alone. Before endotoxin application, a tracheostomy was performed, and venous and arterial catheters were inserted for blood sampling and infusion. MeasurementsIntravital endothelial AT binding was studied by using fluorescence isothiocyanate-marked antibodies during intravital microscopy of intestinal submucosal venules. Systemic prostacyclin, thrombin-AT complex, and fibrinogen concentrations were measured after 4 hrs. Intergroup differences were tested by Kruskal-Wallis analysis of variance on ranks. Main ResultsAT and AT + heparin were equally effective in inhibiting systemic procoagulant turnover as reflected by fibrinogen concentrations. Only the administration of AT + hirudin significantly prevented fibrinogen consumption (p < .05). In contrast with all other treatments, the administration of heparin significantly reduced intravital endothelial AT binding (p < .05). However, prostacyclin concentrations were similarly increased in all endotoxin-challenged study groups irrespective of the anticoagulatory treatment. ConclusionsThere is evidence that heparin in contrast with hirudin prevents AT from being bound to the endothelial cell surface in this experimental model. Under low-dose AT substitution, systemic prostacyclin concentrations do not depend on whether heparin or hirudin is used for thrombin inhibition. These results support the view that heparin may counteract anti-inflammatory AT effects by keeping AT away from its endothelial binding sites; however, the results question the view that decreased endothelial prostacyclin release is solely responsible.

Acute liver necrosis in the HELLP syndrome: successful outcome after orthotopic liver transplantation: a case report

We discuss the case of a 30-year-old primipara woman who developed a liver rupture as a complication of the HELLP syndrome. A liver necrosis and bleeding made a hepatectomy necessary. A portocaval shunt was able to maintain the patient until she underwent urgent liver transplantation. In an excellent state of recovery, the woman and her baby were discharged from the hospital 66 days after having been admitted.

Effects of Prostacyclin Substitution on Systemic Procoagulant Turnover and Cardiorespiratory Variables in Experimental Hypercoagulability

Endotoxin infusion (lipopolysaccharide from Escherichia coli 120 micrograms kg-1 i.v.) was titrated to produce hypercoagulability in rabbits and the effects of prostacyclin (PGI2) treatment (continuous infusion of 6 ng kg-1 min-1 i.v.) on coagulation variables, cardiorespiratory variables, and fibrin deposition in the microcirculation of vital organs were studied. PGI2 infusion did not influence the concentration of soluble fibrin, thrombelastographic variables, or systemic platelet aggregability. Fibrin deposition in the microcirculation of the liver and the lungs was reduced to 50% of that observed in untreated animals (p < 0.01). The antiplatelet properties of PGI2 were unable to reduce experimental endotoxin-induced systemic procoagulant turnover but improved organ perfusion during the initial phase of disseminated intravascular coagulation.

Der Wert der Duplexsonographie nach der orthotopen Lebertransplantation Erfahrungen an 44 Patienten

In a prospective study, 44 patients (11 women, 33 men) who had received orthotopic liver transplants underwent a total of 196 consecutive duplex Doppler ultrasound examinations. The aim of the study was to evaluate the correlation between the pulsatile flow index (PFI) and the damping index (DI) as far as complications as rejection or cholangitis were concerned. The patients were examined five times each on average. The PFI and DI were measured in the hepatic artery, the portal vein and the hepatic veins. The findings were compared with the clinical course (cholangitis, rejection) and the histomorphological diagnosis as determined in biopsy specimens. In biopsy-proven rejection episodes, the sensitivity of the PFI in the hepatic artery was 69.4%, the specificity 72.2%. The sensitivity of the DI in the hepatic vein was 89.4%, the specificity 89.1 %. Combining the two, specificity was more than 90%. PFI and DI in the portal vein bore no apparent relation to clinical course or histomorphological diagnosis. We found duplex Doppler ultrasound extremely beneficial in determining the timing and indication for liver biopsy. In addition, this simple examination, which can be performed as often as desired, accurately shows the transplanted livers response to measures taken to counter rejection.ZusammenfassungIn einer prospektiven Untersuchung wurde an 44 Patienten (33 Männer, 11 Frauen) riach einer elektiven orthotopen Lebertransplantation die Duplexsonographie 196ma1 angewendet. Ziel der Untersuchung war es festzustellen, inwieweit and in welchem zeitlichen Zusammenhang sich die Parameter pulsatiler FluBindex (PFI) und Dämpfungsindex (DI) bei Komplikationen wie Abstoβung und Cholangitis verändern. Der Duplex-Doppler-Ultraschall wurde im Mittel 5mal pro Patient durchgeführt. Die letzte Sonographie erfolgte am Entlassungstag. Bei den Messungen fiber der Leberarterie, der Pfortader und den Lebervenen wurden jeweils der PFI und der DI bestimmt. Die Ergebnisse der Indexuntersuchungen wurden mit dem klinischen Verlauf (Abstoβung, Cholangitis) sowie mit den Resultaten von 88 Biopsiepräparaten der Lebertransplantate in Beziehung gesetzt. Bezüglich einer histologisch gesicherten AbstoBung ergab der PFI (über der Leberarterie gemessen) eine Sensitivität von 69,4 % and eine Spezifitdt von 72,2 %, der DI (über den Lebervenen gemessen) eine Sensitivität von 89,4% und eine Spezifitdt von 89,1 %. Wenn auch die einfach und beliebig oft anwendbare Untersuchungstechnik die bioptische Sicherung einer Rejektion nicht ersetzen kann, so ist sie in hohem Maβe in der Lage, Indikationen zur Biopsie frühzeitig stellen zu lassen und ein Ansprechen auf eine Therapie kurzfristig und mit holier Genauigkeit anzuzeigen.