Ramon Adalia

Anesthetic management of a patient in prone position with a drill bit penetrating the spinal canal at C1-C2, using a laryngeal mask

UNLABELLED Airway management in patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. A 19-yr-old patient was brought to the emergency room in prone position with a drill bit protruding from the posterolateral aspect of his neck. The bit had entered the spinal canal below the first cervical vertebra, and placed near the odontoid peg. He was referred for surgical removal of the drill. The use of an inhaled induction of anesthesia, avoiding muscle relaxants, and ventilation through a laryngeal mask airway inserted in the prone position seemed to offer a satisfactory approach. IMPLICATIONS Management of patients with penetrating neck trauma must guarantee cervical spine stability. Moreover, the prone position increases the risk of difficult ventilation and cervical spine injury. Anesthesia may be induced and the airway can be managed with the patient already in the prone position for surgery.

Hepatic preconditioning after prolonged warm ischemia by means of S-adenosyl-L-methionine administration in pig liver transplantation from non-heart-beating donors.

Background. This study ascertained the effect of S-adenosyl-L-methionine (SAMe) administration on the ischemia-reperfusion injury associated with pig liver transplantation from non-heart-beating donors (NHBDs) after prolonged warm ischemia. Method. Twenty-five animals underwent transplantation with an allograft from an NHBD. After donor cardiac arrest, cardiopulmonary bypass and normothermic recirculation (NR) were performed for 30 min. Ten animals were given SAMe during NR. Donors were cooled to 15°C, and liver procurement was performed. Results. SAMe reduced histologic liver damage 5 days after transplantation. The necrotic area affected 15.9%±14.5% of the liver biopsies in controls and 7.4%±9% in SAMe livers. Six of eight controls and only one of eight survivors in the SAMe group developed ischemic cholangitis. SAMe reduced apoptosis of hepatocytes 5 days after transplantation and apoptosis of sinusoidal endothelial cells at reperfusion and at 5 days. SAMe increased energy charge at the end of NR and favored the balance between adenosine and xanthine. It was also associated with higher portal blood flow (740±59.2 vs. 475.2±65.0 mL/min−1/m−2), hepatic hyaluronic acid extraction (132±72.2 vs. −205.8±64.6 &mgr;g/L), and lower levels of &agr;-glutathione-S-transferase after reperfusion (2,601%±581% with respect to baseline vs. 6,488%±5,612%). Conclusion. SAMe administration during liver procurement from NHBDs prevents liver endothelial, parenchymal, and biliary tract damage. The protective role of SAMe may be partially mediated by the effect of adenosine during liver procurement.

The effects of vasoactive drugs on hepatic blood flow changes induced by CO2 laparoscopy: an animal study.

Laparoscopic surgery is associated with systemic and splanchnic hemodynamic alterations. Recent data suggest that small-dose dobutamine may attenuate the reduction in splanchnic blood flow associated with increments in intraabdominal pressure. We conducted this study to analyze the effects of dopamine and dobutamine on the hepatic circulation in this setting. Twenty-one pigs were anesthetized and mechanically ventilated. A flow-directed pulmonary artery and carotid artery catheters were inserted. Perivascular flowprobes were placed around the main hepatic artery and the portal vein. CO2 was insufflated into the peritoneal cavity to reach an intraabdominal pressure of 15 mm Hg. After 60 min, animals received dopamine (5 &mgr;g · kg−1 · min−1;n = 8), dobutamine (5 &mgr;g · kg−1 · min−1;n = 8), or saline (n = 5) for 30 min. Pneumoperitoneum induced significant increases in heart rate, mean arterial pressure, and systemic vascular resistance, with decreases in cardiac output and hepatic artery and portal vein blood flows. Dobutamine infusion, in contrast to dopamine, corrected, at least in part, cardiac output, systemic vascular resistance, and hepatic artery blood flow alterations, but neither drug restored total hepatic blood flow.

Neuroanesthesia and Brain Death

The pathophysiological changes that occur after the brain death provoke a severe derangement of the cardiocirculatory, respiratory, endocrine, and metabolic systems that lead to the impair of all the organs’ function and the cardiac arrest. Brain-dead patients might be considered as potential organ donors for transplantation, but all the changes that the organism undergoes once it is dead can make this possibility difficult if we are not able to control them. An adequate knowledge of the pathophysiology related to brain death is essential to adopt all the necessary medical measures so that this potential donor can reach the operating room and organ retrieval can be performed in the best possible conditions which would allow a safe transplantation to the recipients. The development of clinical management protocols and the professionalization of the medical teams dealing with this situation are key for the success of transplantation.

Increasing Demand on Master Education for Transplantation

Introduction Transplant Procurement Management (TPM) and the University of Barcelona (UB) offers a Master in Donation and Transplantation since 2004. Until 2010, 3 Spanish, 3 English and 4 Italian editions were held. Since 2011 it has been in English. From 2011, it is a modular program that includes 5 modules: Donation, Transplantation, Management, Training for Trainers and Tissue Banking. The aim of the study is to analyze the total number of students and their profile, as well as the scores in the Transplantation module to evaluate improving measures. Materials and Methods Data including number and profile of the students (gender, nationality and background) and course evaluation scores are organized in 2 periods due to the introduction of the modularity in 2011 (2004-2010 & 2011-2016). For the scores, the first period evaluates the final grade and the second, the scores in the latest modules that has been introduced in the program, the Organ Transplantation module. Results and Discussion Number & profile: Ninety-six and 111 participants were registered in the master in the first and second period respectively. Most of them were women (2004-10: 56.25%; 2011-17:63.13%). The most common background was “medicine” during the first period (47.91%) and the second (57.66%), although background heterogeneity was lower. According to the specialization of the MD, Transplantation is the most frequent (64.93%), followed by Donation (32.46%) and others (2.59%). In the 2014-10 period, the nationalities according to the language were: 1 European for Italian edition, 14 from American countries in the Spanish edition, and 4 in the English edition, mostly from Asia (3). In the 2011-16 period, students were from 32 different countries, mostly European (46) and American (50). Scores: In 2005-2010 students were qualified on an on-site and online course on Donation & Transplantation, an internship and a Dissertation (FMD). The Master’s final grade was Pass/Fail. 100% of participants passed. In 2011-2016, students were evaluated through modules, as well as an internship and a FMD. From 2011-2014 there was no Transplantation module offered. In 2015 and 2016 Organ Transplantation module was introduced to the program according to the background of the participants and their needs, as it was the largest group among the specializations of MD. Results show that Donation has the lowest score (7.32/10) and Transplantation the highest (8.15/10). Training the trainers obtained an 8.20/10, Management an 8.17/10 and Tissue Banking an 7.54/10. Conclusion Considering that the main characteristics of the master are the students’ internationality and heterogeneity, the improving measures must focus on flexibility in the module selection and promoting online modality. Moreover, there is a direct impact in the increasing of the scores when the program is designed according to the needs and background of the participants.

Safety of hepatitis C virus (HCV)-treated donors for kidney transplantation excluding occult HCV infection through kidney biopsies

In 2011, the first Direct Acting Antiviral (DAA) agent was approved for HCV treatment, with high rates of sustained viral response (SVR). Absence of RNA-HCV viral load 12 weeks after end of treatment is considered as permanent viral eradication. However anti-HCV could remain positive despite successful antiviral therapy2.Moreover,HCV can infect extrahepatic tissues, including kidney. The infected extrahepatic tissues might play a role in both HCV persistence and reactivation of infection. This article is protected by copyright. All rights reserved.

The development of a predictive model of graft function in uncontrolled donors after circulatory death: validity of a pulsatile renal preservation machine cut-off value for kidney acceptance

BACKGROUND The criteria for kidney suitability in uncontrolled donors after circulatory death (uDCD) procured after regional normothermic perfusion are based on macroscopic appearance and renal haemodynamic values with final renal resistance (FRR). However, these criteria have not been analysed to predict the future graft function. This study presents a model to predict the outcome in uDCD kidneys and define the predictive FRR value. METHODS All uDCD kidney transplants performed in our hospital from 2004 to 2016 were included. Donors and recipients and pre-transplantation data are described. The endpoint was glomerular filtration rate (GFR) ≥30 mL/min at 6 months after transplantation. RESULTS A total of 194 recipients were included. FRR in donors ≥60 years old was (mean ± SD) 0.27 ± 0.11 versus 0.22 ± 0.09 mmHg/mL/min in donors <60 years (P = 0.042). Kidney survival was 88.2% versus 84% at 12 months and 60.7% versus 30.8% at 120 months (P = 0.067). For the group of recipients from donors ≥60 years, the FRR was 0.37 ± 0.08 mmHg/mL/min in the GFR <30 mL/min group versus 0.18 ± 0.06 mmHg/mL/min in the GFR ≥30 mL/min group (P < 0.001). The value FRR ≥0.3 mmHg/mL/min predicts 59-79% of GFR <30 mL/min [odds ratio = 2.16, 95% confidence interval (CI) 1.80-6.40; P < 0.001]. The predictive accuracy of FRR for GFR by ROC curve was 0.968 (95% CI). The best cut-off for FRR was 0.3 mmHg/mL/min to predict GFR at 6 months with a sensitivity of 67%, specificity of 100%, positive predictive value of 83% and negative predictive value of 92%. CONCLUSIONS Our results suggest that in uDCD donors the combination of donor age ≥60 years together with FRR ≥0.3 mmHg/mL/min could predict poor outcome at 6 months after transplantation in low immunological risk recipients.