Safety of epidural analgesia in an orthotopic liver transplantation

In the literature devoted to the problems of liver transplantation, there is no clearly indicated attitude of the authors to intraoperative epidural blocks, although theoretically the benefits of a sympathetic block are considered. Some sources recommend prophylactic sodium bicarbonate infusion to alleviate post-reperfusion syndrome, but its effectiveness is questionable.Purpose: to present the physiological, biochemical and hematological characteristics of recipients at the stages of orthotopic liver transplantation with an assessment of the feasibility of using sodium bicarbonate for the prevention of reperfusion complications.Materials and methods. An observational study, contains an analysis of data from 39 participants operated on in 2020 in the volume of: hepatectomy, an orthotopic liver transplantation, with an initial assessment on the Child- Turcott- Pugh scale of 11 points. All participants were operated on under general inhalation anesthesia with sevoflurane and thoracic epidural three- component anesthesia according to the Breivik- Niemi method. There are 3 stages of data registration: the beginning of the anhepatic stage; the beginning of the neohepatic stage; the end of the operation.Results and discussion. Significant fluctuations in hemodynamics, violations of the acid-base state and energy metabolism were not revealed; a decrease in hepatic protein synthesis, a shift of the P50 point to the left, and moderate metabolic acidosis did not exceed the levels described in the literature. The dynamics of acidosis, РСО2 and natremia did not depend on the infusion of soda. There was no close correlation between arterial blood pH and lactate concentration.Conclusion. The benefits and safety of epidural anesthesia in orthotopic liver transplants are obvious and make it possible to recommend this component as a routine element of anesthesia during these operations. The indications for sodium bicarbonate infusion should be narrowed and consensus is needed to determine the critical pH value for sodium bicarbonate infusion.

Delayed Cardiotoxicity From a Massive Nortriptyline Overdose Requiring Prolonged Treatment

Purpose A case of a nortriptyline overdose complicated by delayed ventricular arrhythmias necessitating prolonged sodium bicarbonate infusion is presented, along with a review of tricyclic antidepressant (TCA) toxicology and key concepts for massive overdose management. Summary A 61-year-old man presented after an intentional nortriptyline overdose with a possible consumption of up to 2500 mg of nortriptyline. Electrocardiogram on presentation demonstrated QRS widening to 240 milliseconds. Despite treatment with a sodium bicarbonate infusion and further narrowing of his QRS interval, his course was complicated by repeated episodes of wide complex tachycardia. Given these episodes, an elevated quantitative serum nortriptyline level of 468 μg/L on hospital day 6 and persistently positive TCA urine screens, the patient was continued on a sodium bicarbonate infusion until hospital day 14. Based on our patient’s quantitative serum nortriptyline levels, we calculated an elimination half-life of 184 hours, 6 days post ingestion as compared to the reported half-life of nortriptyline of 14 to 51 hours. Conclusion This case demonstrates that at toxic levels of ingestion, routine TCA pharmacokinetics may be unreliable due to delayed absorption, enterohepatic recirculation, large volume of distribution, and saturable kinetics. Therefore, in these cases, pharmacokinetic values derived from routine dosing should not be used to make clinical decisions (such as timing of discontinuation of sodium bicarbonate infusion). We found that urine TCA screens provided similar information to quantitative nortriptyline levels and can be used to guide therapy along the QRS duration.

Implementation and evaluation of high-dose methotrexate administration guidelines

BackgroundHigh-dose methotrexate is used to treat a variety of malignancies. Methotrexate-associated supportive care and the threshold methotrexate level for the discontinuation of supportive care are not consistent among studies. We evaluated the implementation of high-dose methotrexate administration guidelines, which raised the standard threshold methotrexate level for the discontinuation of supportive care from <0.05 to <0.1 µmol.MethodsA single-center, observational analysis of patients receiving high-dose methotrexate from 1 January 2015 to 31 May 2017 was conducted. The primary endpoint was time from the start of the methotrexate infusion until the discontinuation of the sodium bicarbonate infusion, before and after guideline implementation.ResultsFifty-two patients met the inclusion criteria, which comprised of a total of 136 individual methotrexate doses and were included in the retrospective analysis. Twenty-four patients were included in the prospective analysis, which comprised a total of 46 individual methotrexate doses. The primary endpoint, time until discontinuation of the sodium bicarbonate infusion, was a median of 97.7 h in the retrospective group versus 73.2 h in the prospective group (p = 0.098). Secondary endpoints also favored patients in the prospective group, including hours of hospitalization, number of methotrexate levels checked, weight gained during admission, and adherence to the guideline.ConclusionAmong patients who received high-dose methotrexate, implementation of a guideline using a methotrexate threshold of <0.1 µmol was able to significantly decrease the time to discontinuation of supportive care and subsequently may lead to early hospital discharge given that we did not show a statistical significance.