Youri Vater

A multicenter evaluation of safety of early extubation in liver transplant recipients

Small single‐institutional studies performed prior to the introduction of organ allocation using the Model for End‐Stage Liver Disease (MELD) suggest that early airway extubation of liver transplant recipients is a safe practice. We designed a multicenter study to examine adverse events associated with early extubation in patients selected for liver transplantation using MELD score. A total of 7 institutions extubated all patients meeting study criteria and reported adverse events that occurred within 72 hours following surgery. Adverse events were uncommon: occurring in only 7.7% of 391 patients studied. Most adverse events were pulmonary or surgically related. Pulmonary complications were usually minor, requiring only an increase in ambient oxygen concentration. The majority of surgical adverse events required additional surgery. Analysis of a limited set of perioperative variables suggest that blood transfusions and technical factors were associated with an increased risk of adverse events. In conclusion, while early extubation appears to be safe under specified circumstances, there are performance differences between institutions that remain to be explained. Liver Transpl 13:1557–1563, 2007.

Intraosseous emergency access by physicians wearing full protective gear

OBJECTIVES To assess prospectively and randomly the feasibility, speed, and success rate of establishing an intraosseous access using the Bone Injection Gun (BIG) while wearing antichemical outfits. METHODS Attempts to introduce intraosseous injection with or without a full protective gear (antichemical body suit, face mask, and butyl gloves) were performed using a turkey bone model. Time to proper placement was measured. RESULTS The average time to successfully insert the BIGs needle while wearing a protective gear was 32 +/- 3 seconds compared with 22 +/- 2 seconds (p<0.05) without the outfit. Success rate was greater than or equal to 80%. When failure occurred, a second attempt always proved successful. CONCLUSIONS The intraosseous insertion of the BIGs needle is rapid and easy but requires 50% more time when wearing protective gear than without it. Its use during emergent treatment of toxic mass casualty is of potential benefit and needs further investigation.

A Randomized Clinical Trial Testing the Anti-Inflammatory Effects of Preemptive Inhaled Nitric Oxide in Human Liver Transplantation

Decreases in endothelial nitric oxide synthase derived nitric oxide (NO) production during liver transplantation promotes injury. We hypothesized that preemptive inhaled NO (iNO) would improve allograft function (primary) and reduce complications post-transplantation (secondary). Patients at two university centers (Center A and B) were randomized to receive placebo (n = 20/center) or iNO (80 ppm, n = 20/center) during the operative phase of liver transplantation. Data were analyzed at set intervals for up to 9-months post-transplantation and compared between groups. Patient characteristics and outcomes were examined with the Mann-Whitney U test, Student t-test, logistic regression, repeated measures ANOVA, and Cox proportional hazards models. Combined and site stratified analyses were performed. MELD scores were significantly higher at Center B (22.5 vs. 19.5, p<0.0001), surgical times were greater at Center B (7.7 vs. 4.5 hrs, p<0.001) and warm ischemia times were greater at Center B (95.4 vs. 69.7 min, p<0.0001). No adverse metabolic or hematologic effects from iNO occurred. iNO enhanced allograft function indexed by liver function tests (Center B, p<0.05; and p<0.03 for ALT with center data combined) and reduced complications at 9-months (Center A and B, p = 0.0062, OR = 0.15, 95% CI (0.04, 0.59)). ICU (p = 0.47) and hospital length of stay (p = 0.49) were not decreased. iNO increased concentrations of nitrate (p<0.001), nitrite (p<0.001) and nitrosylhemoglobin (p<0.001), with nitrite being postulated as a protective mechanism. Mean costs of iNO were

Effects of vasoactive agents on blood loss and transfusion requirements during pre-reperfusion stages of the orthotopic liver transplantation

1,020 per transplant. iNO was safe and improved allograft function at one center and trended toward improving allograft function at the other. ClinicalTrials.gov with registry number 00582010 and the following URL:http://clinicaltrials.gov/show/NCT00582010.

Anesthetic implications of the new anticoagulant and antiplatelet drugs

Objective: To evaluate the effects of vasoactive drugs, specifi cally low-dose vasopressin and phenylephrine infusions, on blood loss / transfusion requirements during dissection and anhepatic (pre-reperfusion) stages of orthotopic liver transplantations. Methods: A retrospective analysis of 110 orthotopic liver transplantation (OLT) cases was performed. The variables studied were: blood loss before and after reperfusion of the liver graft; blood volumes returned by cell-saver and amounts of transfused blood products; amounts of infused colloids and crystalloids; hemodynamic parameters such as MABP, MPAP, CO/CI, SVR; dosage of vasoactive drugs. Short – and long-term outcome measures included length-of stay (LOS), ICU LOS, 48 –hours return to the OR rate, incidence of the primary non-function of the liver graft, amounts of fresh frozen plasma (FFP) and cryoprecipitate, administered in the ICU, and 1-year mortality. The study subjects were allocated in two groups. Study group consisted of 15 patients that received a low-dose (0.04U/min) vasopressin infusion alongside with other vasoactive agents, such as phenylephrine and epinephrine, during the dissection and anhepatic stages of the procedure. Control group consisted of 95 patients, that received the same vasoactive agents except a lowdose vasopressin infusion. Anesthetic and transfusion management in both groups were otherwise identical. Results: The estimated blood loss before reperfusion of the liver graft was in 50.2% lower (p=0.0094) and total blood loss was in 38.8% lower ( p=0.0548) in the vasopressin group in comparison with control group of subjects of the same age, sex and with the same MELD score. No statistically signifi cant differences neither in hemodynamic parameters between the two groups, nor in transfusion requirements and volumes of crystalloid and colloids infused, were detected. No differences were found also in long-term outcome parameters. Conclusions: The decrease in blood loss in the vasopressin group may be attributed to the use of a vasopressin infusion. A low-dose (0.04U/min) vasopressin infusion may be an effective technique for blood loss reduction during the pre-reperfusion stages in orthotopic liver transplantation.

Detrimental graft survival of size-mismatched graft for high model for end-stage liver disease recipients in liver transplantation

In this review, we discuss the anesthetic implications of the new anticoagulant and antiplatelet drugs, focusing our discussion mainly on neuroaxial/regional anesthesia and central catheter placement issues. We offer practical recommendations for their use.

Drug management in emergent liver transplantation of mitochondrial disorder carriers: review of the literature

In orthotopic liver transplantation (OLT) size‐mismatch may cause adverse outcomes. We previously reported on a method to predict donor‐recipient size‐mismatch using the body surface area index (BSAi). In this study, we hypothesized that graft survival of size‐mismatch transplantation deteriorates with higher model for end‐stage liver disease (MELD) score at transplantation.

Drug management in emergent liver transplantation of mitochondrial disorder carriers

Vater Y, Dembo G, Martay K, Klein Y, Vitin A, Weinbroum AA. Drug management in emergent liver transplantation of mitochondrial disorder carriers: review of the literature.
Clin Transplant 2010 DOI: 10.1111/j.1399‐0012.2009.01203.x
© 2010 John Wiley & Sons A/S.

Intraoperative epoprostenol and nitric oxide for severe pulmonary hypertension during orthotopic liver transplantation: a case report and review of the literature.

Vater Y, Dembo G, Martay K, Klein Y, Vitin A, Weinbroum AA. Drug management in emergent liver transplantation of mitochondrial disorder carriers: review of the literature.
Clin Transplant 2010 DOI: 10.1111/j.1399‐0012.2009.01203.x
© 2010 John Wiley & Sons A/S.