Lung transplantation for idiopathic pulmonary arterial hypertension has the highest reported postoperative mortality of all indications. Reasons lie in the complexity of treatment of these patients ...and the frequent occurrence of postoperative left ventricular failure. Transplantation on intraoperative extracorporeal membrane oxygenation support instead of cardiopulmonary bypass and even more the prolongation of extracorporeal membrane oxygenation into the postoperative period helps to overcome these problems. We reviewed our experience with this concept.
All patients undergoing bilateral lung transplantation for idiopathic pulmonary arterial hypertension on intraoperative extracorporeal membrane oxygenation with or without prophylactic extracorporeal membrane oxygenation prolongation into the postoperative period between January 2000 and December 2014 were retrospectively analysed.
Forty-one patients entered the study. Venoarterial extracorporeal membrane oxygenation support was prolonged into the postoperative period for a median of 2.5 days (range 1-40). Ninety-day, 1-, 3- and 5-year survival rates for the patient collective were 92.7%, 90.2%, 87.4% and 87.4%, respectively. When compared with 31 patients with idiopathic pulmonary arterial hypertension transplanted in the same period of time without prolongation of extracorporeal membrane oxygenation into the postoperative period, the results compared favourably (83.9%, 77.4%, 77.4%, and 77.4%; P = 0.189). Furthermore, these results are among the best results ever reported for this particularly difficult patient population.
Bilateral lung transplantation for idiopathic pulmonary arterial hypertension with intraoperative venoarterial extracorporeal membrane oxygenation support seems to provide superior outcome compared with the results reported about the use of cardiopulmonary bypass. Prophylactic prolongation of venoarterial extracorporeal membrane oxygenation into the early postoperative period provides stable postoperative conditions and seems to further improve the results.
Several biomarkers have been suggested as early predictors of acute kidney injury (AKI) after orthotopic liver transplantation (OLT). Neutrophil gelatinase-associated lipocalin-2 (NGAL) appears to be ...a promising predictor of AKI after OLT, but the clinical benefit remains to be proven. Recently, systemic macrophage migration inhibitory factor (MIF) has been proposed as early indicator for requirement of renal replacement therapy after OLT. The aim of this prospective, observational pilot study was to compare the predictive values of serum and urinary MIF for severe AKI after OLT to those of serum and urinary NGAL.
Concentrations of MIF and NGAL were measured in serum and urine samples collected from patients undergoing OLT. Acute kidney injury was classified according to the KDIGO criteria, with stages 2 and 3 summarized as severe AKI. Areas under the receiver operating curves (AUC) were calculated to assess predictive values of MIF and NGAL for the development of severe AKI.
Forty-five patients (mean age 55±8 years) were included. Nineteen patients (38%) developed severe AKI within 48 hours after reperfusion. At the end of OLT, serum MIF was predictive of severe AKI (AUC 0.73; 95% confidence intervals, CI 0.55-0.90; P = 0.03), whereas urinary MIF, serum NGAL, and urinary NGAL were not. On the first postoperative day, serum MIF (AUC 0.78; CI 0.62-0.93; P = 0.006), urinary MIF (AUC 0.71; CI 0.53-0.88; P = 0.03), and urinary NGAL (AUC 0.79; CI 0.64-0.93; P = 0.02) were predictive for severe AKI, while serum NGAL was not.
In the setting of OLT, MIF and NGAL had similar predictive values for the development of severe AKI.
Background Neonates and small infants with congenital cardiac disease undergoing cardiac surgery represent major challenges facing paediatric anaesthesia and perioperative medicine. Aims. We here ...aimed to investigate the success rates in performing ultrasound (US) guided central venous catheter insertion (CVC) in neonates and small infants undergoing cardiac surgery, and to evaluate the practicability and feasibility of thereby using a novel wireless US transducer (WUST). Methods Thirty neonates and small infants with a maximum body weight of 10 kg and need for CVC before cardiac surgery were included in this observational trial and were subdivided into two groups according to their weight: < 5 kg and greater than or equai to 5 kg. Cannulation success, failure rate, essential procedure related time periods, and complications were recorded and the clinical utility of the WUST was assessed by a 5-point Likert scale. Results In total, CVC-insertion was successful in 27 (90%) of the patients and the first attempt was successful in 24 (78%) of patients. Success rates of CVC were 80% < 5 kg and 100% greater than or equai to5 kg. Comparing the two groups we found a clear trend towards longer needle insertion time in patients weighing < 5 kg (33 28-69 vs. 24 15-37s, P = .07), whereas, the total time for catheter insertion and the duration of the whole procedure were similar in both groups (199 167-228 vs. 178 138-234 and 720538-818 vs. 660 562-833s. In total, we report 3 (10%) cases of local hematoma as procedure-related complications. Assessments of the WUST revealed very good survey results for all parameters of practicability and handling (all ratings between 4.5 and 5.0). Conclusion Although difficulties in CVC-placement seem to relate to vessel size and patient's weight, US guided CVC-insertion represents a valuable, fast, and safe intervention in neonates and small children undergoing cardiac surgery. Using the WUST is feasible for this clinical application and may aid in efforts aiming to optimize perioperative care. Trial registration Wireless US-guided CVC placement in infants; Clinicaltrials.gov: NCT04597021; Date of Registration: 21October, 2020; retrospectively registered. Keywords: Wireless ultrasound, Central venous catheter, Ultrasound guided catheter placement, Infants, Congenital heart disease
The product of the concentrations of urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor binding protein-7 (urinary TIMP-2 × IGFBP-7) has been suggested as biomarker for ...early detection of acute kidney injury (AKI) in various clinical settings. However, the performance of urinary TIMP-2 × IGFBP-7 to predict AKI has never been assessed in patients undergoing orthotopic liver transplantation (OLT). Thus, the aim of this study was to assess the early predictive value of urinary TIMP-2 × IGFBP-7 for the development of AKI after OLT.
In this observational study, urinary TIMP-2 × IGFBP-7 was measured in samples from adult OLT patients. AKI was diagnosed and classified according to KDIGO criteria. Areas under the receiver operating curves (AUC) were calculated to assess predictive values of urinary TIMP-2 × IGFBP-7 for the development of AKI.
Forty patients (mean age 55 ± 8 years) were included. Twenty-eight patients (70%) developed AKI stage 1, 2, or 3 within 48 h after OLT. Urinary TIMP-2 × IGFBP-7 was not predictive for AKI at the end of OLT (AUC: 0.54, CI 0.32-0.75, P = 0.72), at day 1 (AUC: 0.60, CI 0.41-0.79, P = 0.31), or day 2 after OLT (AUC: 0.63, CI 0.46-0.8, P = 0.18).
Based on our results, routine clinical use of urinary TIMP-2 × IGFBP-7 cannot be recommended for risk assessment of AKI in patients undergoing OLT.
Background IL-33, a member of the IL-1 family, induces the production of pro-inflammatory and Th2-associated cytokines and may also serve as an ‘alarmin’ similar to HMGB1. Soluble ST2 has been ...implicated as a decoy receptor, to attenuate Th2 inflammatory responses. The relevance of both molecules in hepatic failure is unknown. Materials and Methods The trial was a prospective preliminary study in a university hospital surgical ICU; 11 patients with acute liver failure (ALF) and 12 patients with acute-on-chronic liver failure (ACLF), who were admitted to the ICU; 14 patients with chronic hepatic failure (CHF) awaiting liver transplantation; 13 healthy individuals served as controls. IL-33 and soluble ST2 concentrations were determined by enzyme linked immunosorbent assay (ELISA). Results The concentration of IL-33 and soluble ST2 was significantly higher in ALF, ACLF, and CHF patients compared with the controls. Soluble ST2 serum concentration was significantly elevated in ALF and ACLF compared with CHF; moreover, soluble ST2 was significantly higher in CHF compared with healthy controls. IL-33 and soluble ST2 serum levels correlated significantly (r = 0.6117, P < 0.0001). Moreover, there was a correlation between IL-33 serum levels and alanine aminotransferase (ALT) activity in CHF, ALF, and ACLF patients (r = 0.4321, P = 0.0171). Conclusion Our data provide evidence for elevated levels of IL-33 and soluble ST2 in liver failure, which could a sign of immune hyperactivation, and/or a mechanism to down-regulate inflammation. Especially, soluble ST2 maybe useful to discern acute from chronic hepatic failure or to monitor the course and the severity of the disease.
Plasma disappearance rate of indocyanine green (PDRICG) has been proposed for assessment of liver function in liver transplants donors and recipients, in patients with chronic liver failure, and as a ...prognostic factor in critically ill patients. The assessment of PDRICG using a newly developed noninvasive digital pulse densitometry method was simultaneously compared to invasive aortic fiber‐optic method in patients undergoing orthotopic liver transplantation (OLT). Fourteen consecutive liver transplant candidates (11 male, 3 female) were prospectively enrolled into the study. A 4F aortic catheter with an integrated fiber‐optic device and a thermistor was inserted via a femoral artery sheath for invasive aortic (INV) PDRICG assessment in all patients. The fiber‐optic device was connected to a computer system (COLD‐Z021, PULSION Medical Systems, Munich, Germany). A finger‐piece sensor was used for non‐invasive (NINV) pulse‐densitometric PDRICG assessment. For the PDRICG assessment .5 mg/kg of ICG in cooled saline (10‐15 mL) was injected through a central venous catheter. The assessments of PDRICG were performed after induction of anesthesia, after clamping of the hepatic artery, after clamping of the inferior vena cava, after reperfusion of the graft, and on the first postoperative day. During the PDRICG measurements, the investigators were blinded for the results of the noninvasive monitoring. Seventy‐one pairs of measurements were performed successfully. PDRICG ranged from 0%/min to 43.8 %/min (11.6%/min ± 9.6 %/min, mean ± SD) for invasive and from 2.6%/min to 36.1 %/min (10%/min ± 7.6 %/min, mean ± SD) for noninvasive assessment method. The linear regression analysis yielded the equation: PDRICGNINV = 1.493 ± 0.735 × PDRICGINV, with a correlation coefficient of r = 0.93 (P < .0001). The analysis according to Bland and Altman showed a good agreement between the PDRICGNINV and PDRICGINV with a mean bias 1.5 ± 3.8 for all measurements. In conclusion, according to these results, the noninvasive transcutaneous pulse‐densitometric method correlates well with the invasive aortic fiber‐optic method and thus can be used in patients undergoing liver transplantation. (Liver Transpl 2004;10:1060–1064.)
Prone positioning has become a standard therapy in acute respiratory distress syndrome to improve oxygenation and decrease mortality. However, little is known about prone positioning in lung ...transplant recipients. This large, singe-center analysis investigated whether prone positioning improves gas exchange after lung transplantation.
Clinical data of 583 patients were analyzed. Prone position was considered in case of impaired gas exchange Pao2/fraction of oxygen in inhaled air (<250), signs of edema after lung transplantation, and/or evidence of reperfusion injury. Patients with hemodynamic instability or active bleeding were not proned. Impact of prone positioning (n = 165) on gas exchange, early outcome and survival were determined and compared with patients in supine positioning (n = 418).
Patients in prone position were younger, more likely to have interstitial lung disease, and had a higher lung allocation score. Patients were proned for a median of 19 hours (interquartile range,15-26) hours). They had significantly lower Pao2/fraction of oxygen in inhaled air (227 ± 96 vs 303 ± 127 mm Hg, P = .004), and lower lung compliance (24.8 ± 9.1 mL/mbar vs 29.8 ± 9.7 mL/mbar, P < .001) immediately after lung transplantation. Both values significantly improved after prone positioning for 24 hours (Pao2/fraction of oxygen ratio: 331 ± 91 mm Hg; lung compliance: 31.7 ± 20.2 mL/mbar). Survival at 90 days was similar between the 2 groups (93% vs 96%, P = .105).
Prone positioning led to a significant improvement in lung compliance and oxygenation after lung transplantation. Prospective studies are needed to confirm the benefit of prone positioning in lung transplantation.
Acute kidney injury (AKI) is a serious complication in postoperative ICU patients. The incidence of AKI varies substantially based on the type of surgery and definition used. This study focuses on ...the incidence of AKI in postoperative ICU patients using full KDIGO criteria and related outcomes regarding to different types of surgery.
Retrospective cohort study.
Tertiary level university hospital, eight anaesthesiological/surgical ICUs, between 2016 and 2018.
6261 adult patients.
Primary outcome was 28-day all-cause mortality in different stages of AKI according to complete KDIGO criteria.
We found 3497 (55.9%) postoperative ICU patients with AKI. The severity distribution of AKI stage 1 to 3 was 19.7%, 28.4% and 7.8%, respectively, and 235 (4%) patients received RRT. The 28-day mortality was 3% (n = 205). Increasing AKI severity was associated with increased 28-day mortality when adjusted for other variables (AKI 2°: OR 2.81; 95% CI 1.55 to 5.24; p < 0.001 and AKI 3°: OR 11.37.; 95% CI 5.91 to 22.55; p < 0.001). Besides AKI stages 2 and 3, age (OR 1.02; 95% CI 1.01 to 1.04, p < 0.001), NYHA IV (OR 2.23; 95% CI 1.03 to 4.43, p = 0.042), need for surgical reintervention within 48 h (OR 2.92; 95% CI 1.76 to 4.72, p = 0.001), urgent surgery (OR 1.78; 95% CI 1.15 to 2.71, p = 0.01), emergency surgery (OR 2.63; 95% CI 1.58 to 4.31, p = 0.001), vascular surgery (OR 2.01; 95% CI 1.06 to 3.98, p = 0.033), and orthopedic and trauma surgery (OR 3.79; 95% CI 1.98 to 7.09, p < 0.001) versus cardiac surgery was significantly associated with increased risk for 28-days mortality in multivariate analysis.
AKI based on full KDIGO criteria is very common in postoperative ICU patients and it is associated with stepwise increase in 28-days mortality.
•Incidence & outcome of AKI classified by creatinine (SCr) and urine output (UO) criteria are unknown in surgical ICU patients•AKI occurred in nearly 56% of patients within the first week after ICU admission and is associated increased mortality.•The assessment of AKI based on SCr alone failed to identify AKI in many ICU patients.•The assessment of AKI based on both criteria, SCr and UO, increased the AKI incidence by 35%.•Adding the UO criteria unveiled a much higher number of patients with AKI in postoperative ICU patients.
Endothelial glycocalyx participates in the maintenance of vascular integrity, and its perturbations cause capillary leakage, loss of vascular responsiveness, and enhanced adhesion of leukocytes and ...platelets. We hypothesized that marked shedding of the glycocalyx core protein, syndecan-1, occurs in end-stage liver disease (ESLD) and that it increases during orthotopic liver transplantation (OLT). We further evaluated the effects of general anesthesia on glycocalyx shedding and its association with acute kidney injury (AKI) after OLT.
Thirty consecutive liver transplant recipients were enrolled in this prospective study. Ten healthy volunteers served as a control. Acute kidney injury was defined by Acute Kidney Injury Network criteria.
Plasma syndecan-1 was significantly higher in ESLD patients than in healthy volunteers (74.3 ± 59.9 vs 10.7 ± 9.4 ng/mL), and it further increased significantly after reperfusion (74.3 ± 59.9 vs 312.6 ± 114.8 ng/mL). The type of general anesthesia had no significant effect on syndecan-1. Syndecan-1 was significantly higher during the entire study in patients with posttransplant AKI stage 2 or 3 compared to patients with AKI stage 0 or 1. The area under the curve of the receiver operating characteristics curve of syndecane-1 to predict AKI stage 2 or 3 within 48 hours after reperfusion was 0.76 (95% confidence interval, 0.57-0.89, P = 0.005).
Patients with ESLD suffer from glycocalyx alterations, and ischemia-reperfusion injury during OLT further exacerbates its damage. Despite a higher incidence of AKI in patients with elevated syndecan-1, it is not helpful to predict de novo AKI. Volatile anesthetics did not attenuate glycocalyx shedding in human OLT.
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