Ex-situ hepatectomy: Indications, Techniques and Results

Ex situ hepatectomy is a novel approach, used in treating complicated liver tumors, which are otherwise unresectable via conventional methods including organ perfusion, liver transplant, hemodynamic management, vascular reconstruction or even extended hepatic resection. The Ex situ hepatectomy technique denotes the entire removal of the infected liver, which is then perfused in a cold preservation solution, which allows the surgeon to remove tumors, which were otherwise unreachable when the liver is situated in the body. In so doing, the tumor is restricted ex situ on the surgeon stable, while the remaining liver is implanted orthotopically. Notably, the works on Ex situ hepatectomy techniques are credited to Pichlmary 1990, who proposed the surgical approach in the treatment of bilateral liver leiomyosarcoma. More to that, there are only a handful of successful Ex situ hepatectomy cases which have been recorded on a global scale, given the complexity of the operation. Secondary as well as primary liver tumors are some of the most commonly occurring liver tumors in humans.

Postoperative Management of Lung Transplant Recipients in the Intensive Care Unit

The number of lung transplantations is progressively increasing worldwide, providing new challenges to interprofessional teams and the intensive care units. The outcome of lung transplantation recipients is critically affected by a complex interplay of particular pathophysiologic conditions and risk factors, knowledge of which is fundamental to appropriately manage these patients during the early postoperative course. As high-grade evidence-based guidelines are not available, the authors aimed to provide an updated review of the postoperative management of lung transplantation recipients in the intensive care unit, which addresses six main areas: (1) management of mechanical ventilation, (2) fluid and hemodynamic management, (3) immunosuppressive therapies, (4) prevention and management of neurologic complications, (5) antimicrobial therapy, and (6) management of nutritional support and abdominal complications. The integrated care provided by a dedicated multidisciplinary team is key to optimize the complex postoperative management of lung transplantation recipients in the intensive care unit.

The effect of the volemic and cardiac status on brain oxygenation in patients with subarachnoid hemorrhage: a bi-center cohort study

Background Fluid management in patients after subarachnoid hemorrhage (SAH) aims at the optimization of cerebral blood flow and brain oxygenation. In this study, we investigated the effects of hemodynamic management on brain oxygenation by integrating advanced hemodynamic and invasive neuromonitoring. Methods This observational cohort bi-center study included data of consecutive poor-grade SAH patients who underwent pulse contour cardiac output (PiCCO) monitoring and invasive neuromonitoring. Fluid management was guided by the transpulmonary thermodilution system and aimed at euvolemia (cardiac index, CI ≥ 3.0 L/min/m2; global end-diastolic index, GEDI 680–800 mL/m2; stroke volume variation, SVV < 10%). Patients were managed using a brain tissue oxygenation (PbtO2) targeted protocol to prevent brain tissue hypoxia (BTH, PbtO2 < 20 mmHg). To assess the association between CI and PbtO2 and the effect of fluid challenges on CI and PbtO2, we used generalized estimating equations to account for repeated measurements. Results Among a total of 60 included patients (median age 56 [IQRs 47–65] years), BTH occurred in 23% of the monitoring time during the first 10 days since admission. Overall, mean CI was within normal ranges (ranging from 3.1 ± 1.3 on day 0 to 4.1 ± 1.1 L/min/m2 on day 4). Higher CI levels were associated with higher PbtO2 levels (Wald = 14.2; p < 0.001). Neither daily fluid input nor fluid balance was associated with absolute PbtO2 levels (p = 0.94 and p = 0.85, respectively) or the occurrence of BTH (p = 0.68 and p = 0.71, respectively). PbtO2 levels were not significantly different in preload dependent patients compared to episodes of euvolemia. PbtO2 increased as a response to fluid boluses only if BTH was present at baseline (from 13 ± 6 to 16 ± 11 mmHg, OR = 13.3 [95% CI 2.6–67.4], p = 0.002), but not when all boluses were considered (p = 0.154). Conclusions In this study a moderate association between increased cardiac output and brain oxygenation was observed. Fluid challenges may improve PbtO2 only in the presence of baseline BTH. Individualized hemodynamic management requires advanced cardiac and brain monitoring in critically ill SAH patients.

The First 24 h Hemodynamic Management in NICU after Revascularization Surgery in Moyamoya Disease

Objective. To evaluate whether hemodynamic factors are risk factors for prognosis in moyamoya disease (MMD). Materials and Methods. The retrospective study reviewed a single-center MMD cohort in Huashan Hospital from August 2017 to January 2020. Stroke events in 30 days and follow-up modified Rankin Scale (mRS) grade were recorded. Systematic assessments with perioperative mean arterial pressure (MAP), red blood cell (RBC) parameters, and fluid management were also conducted. Logistic regressions were applied to evaluate the predictors of worse outcomes. Data was analyzed using SPSS 24.0. Results. Admission to neurological intensive care unit (NICU) totalled about 347 after revascularization surgery. The result showed that the higher the postoperative MAP level (favorable group 95.7 ± 11.4 mmHg vs. unfavorable group 103.6 ± 10.4 mmHg, p < 0.001 ) and the greater the MAP variability (favorable group 0.26 ± 13.2 vs. unfavorable group 7.2 ± 13.5 , p = 0.006 ) were, the higher the patient’s follow-up mRS grade was. What is more, a higher early postoperative Hb level also seemed to predict a worse long-term clinical outcome (favorable group 116.9 ± 17.1 g/L vs. unfavorable group 123.7 ± 13.0 g/L, p = 0.03 ), but the difference disappeared after adjusting sex and age. Logistic regression analyses showed that a higher level of postoperative MAP ( β = 0.024 , 95% CI (0.004, 0.044), and p = 0.02 ) within the first 24 h in NICU might be the short-term risk factor. For long-term outcome, a higher level ( β = 1.058 , 95% CI (1.022, 1.096), and p = 0.001 ) and a greater variability ( β = 30.982 , 95% CI (2.112, 454.414), and p = 0.01 ) of postoperative MAP might be the negative predictors of mRS grade. Conclusions. The early postoperative hemodynamic management might be extremely critical for patients with MMD. Both high postoperative MAP levels and large MAP variability might affect the prognosis. What is more, we also found that a higher postoperative Hb level might be related with a worse outcome.

ASSOCIATION OF SERUM LACTATE LEVELS WITH CREATINE KINASE – MB AND LACTATE DEHYDROGENASE IN PATIENTS WITH MYOCARDIAL INFARCTION

Objectives: Myocardial infarction is the most common form of coronary heart disease, the commonest cause of worldwide mortality. The present biochemical markers take atleast 6 hours for elevation following an episode of myocardial infarction. There is a need for sensitive marker for early diagnosis and prognosis. Lactate, the end product of anaerobic glycolysis is found to be elevated in many critical illnesses. Thus the study was undertaken to assess the levels of serum lactate in patients with myocardial infarction and to correlate it with the frequently used enzymatic markers for the diagnosis of myocardial infarction, i.e creatine kinase – MB and lactate dehydrogenase Methods: Fifty age and sex matched controls and fty cases of myocardial infarction were included in the study. Serum creatine kinase – MB, lactate dehydrogenase and lactate were estimated in these subjects. Results:The serum lactate levels were signicantly higher among cases when compared to controls. The serum lactate levels positively correlated with serum creatine kinase – MB among cases but not with lactate dehydrogenase. Conclusions: We conclude that serum lactate is altered in patients with myocardial infarction and may be considered as a prognostic risk factor in these patients. Further studies are needed to nd the cut-off value of serum lactate for assistance in the hemodynamic management of these patients.