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Background: Fluid management practices during and after liver transplantation vary widely among centers despite better understanding of the pathophysiology of end‐stage liver disease and of the effects of commonly used fluids. This reflects a lack of high quality trials in this setting, but also provides a rationale for both systematic review of all relevant studies in liver recipients and evaluation of new evidence from closely related domains, including hepatology, non‐transplant abdominal surgery, and critical care. Objectives: To develop evidence‐based recommendations for perioperative fluid management to optimize immediate and short‐term outcomes following liver transplantation. Data sources: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating the following postoperative outcomes: acute kidney injury, respiratory complications, operative blood loss/red cell units required, and intensive care length of stay. PROSPERO protocol ID: CRD42021241392 Results: Following expert panel review, 18 of 1624 screened studies met eligibility criteria for inclusion in the final quantitative synthesis. These included six single center RCTs, 11 single center observational studies, and one observational study comparing centers with different fluid management techniques. Definitions of interventions and outcomes varied between studies. Recommendations are therefore based substantially on expert opinion and evidence from other clinical settings. Conclusions: A moderately restrictive or "replacement only" fluid regime is recommended, especially during the dissection phase of the transplant procedure. Sustained hypervolemia, based on absence of fluid responsiveness, elevated filling pressures and/or echocardiographic findings, should be avoided (Quality of Evidence: Moderate | Grade of Recommendation: Weak for restrictive fluid regime. Strong for avoidance of hypervolemia). Mean Arterial Pressure (MAP) should be maintained at >60–65 mmHg in all cases (Quality of Evidence: Low | Grade of Recommendation: Strong). There is insufficient evidence in this population to support preferential use of any specific colloid or crystalloid for routine volume replacement. However, we recommend against the use of 130/.4 HES given the high incidence of AKI in this population. [ABSTRACT FROM AUTHOR]

Background: COVID-19 may result in multiorgan failure and death. Early detection of patients at risk may allow triage and more intense monitoring. The aim of this study was to develop a simple, objective admission score, based on laboratory tests, that identifies patients who are likely going to deteriorate.Methods: This is a retrospective cohort study of all COVID-19 patients admitted to a tertiary academic medical center in New York City during the COVID-19 crisis in spring 2020. The primary combined endpoint included intubation, stage 3 acute kidney injury (AKI), or death. Laboratory tests available on admission in at least 70% of patients (and age) were included for univariate analysis. Tests that were statistically or clinically significant were then included in a multivariate binary logistic regression model using stepwise exclusion. 70% of all patients were used to train the model, and 30% were used as an internal validation cohort. The aim of this study was to develop and validate a model for COVID-19 severity based on biomarkers.Results: Out of 2545 patients, 833 (32.7%) experienced the primary endpoint. 53 laboratory tests were analyzed, and of these, 47 tests (and age) were significantly different between patients with and without the endpoint. The final multivariate model included age, albumin, creatinine, C-reactive protein, and lactate dehydrogenase. The area under the ROC curve was 0.850 (CI [95%]: 0.813, 0.889), with a sensitivity of 0.800 and specificity of 0.761. The probability of experiencing the primary endpoint can be calculated as p=e(-2.4475+0.02492age - 0.6503albumin+0.81926creat+0.00388CRP+0.00143LDH)/1+e(-2.4475+ 0.02492age - 0.6503albumin+0.81926creat+0.00388CRP+0.00143LDH).Conclusions: Our study demonstrated that poor outcome in COVID-19 patients can be predicted with good sensitivity and specificity using a few laboratory tests. This is useful for identifying patients at risk during admission. [ABSTRACT FROM AUTHOR]

Aim: Acute kidney injury (AKI) after cardiac surgery increases morbidity and mortality. Different definitions for AKI have been used such as Acute Kidney Injury Network (AKIN), Kidney Disease: Improving Global Outcomes (KDIGO) or risk, injury, failure, loss, end‐stage kidney disease (RIFLE). The aim of this study is to determine the best definition of AKI after cardiac surgery with the largest impact on the outcome. Methods: This retrospective study of cardiac surgery patients compared the incidence and effect on outcome (90‐day and 1‐year mortality) of different definitions of AKI: RIFLE, AKIN and KDIGO. Additionally, we defined transient AKI (increase in serum creatinine that resolved in <72 hours), sustained (increase in serum creatinine within 48 hours that remained for >72 hours), and late (increase in serum creatinine after 48 hours). Results: Of the included 1551 patients, 410 patients developed AKI defined by AKIN criteria, 449 defined by KDIGO and 217 defined by RIFLE‐Risk criteria. Hundred and nine patients developed transient AKI (6.9%), 183 patients had sustained AKI (11.6%), and 106 patients had late AKI (6.7%). The best definition with the highest positive likelihood ratio was RIFLE‐Risk (positive likelihood ratio = 2.32) followed by "sustained AKI" (positive likelihood ratio = 2.27). AKI defined by AKIN criteria missed all 80 patients with late AKI and 39 patients with KDIGO AKI. Conclusion: Risk, injury, failure, loss, end‐stage kidney disease‐risk was the best definition of AKI as determined by the ability to predict short‐term mortality. A substantial number of patients developed AKI only after 48 hours, and these were missed when using AKIN criteria. AKIN criteria are not sensitive enough to capture all episodes of AKI in this population. Summary at a glance: This paper compares acute kidney injury scoring systems retrospectively applied to patients undergoing cardiac procedures. It highlights the differences in specificity and sensitivity of these scoring systems for predicting mortality and underscores the deficiencies of relying on a single scoring system to determine risk. [ABSTRACT FROM AUTHOR]

Mechanical circulatory support is increasingly used and may bring about unique challenges. Most support systems require systemic anticoagulation and the need for anticoagulation must be balanced against the increased risk for bleeding. We report the case of a young man awaiting heart retransplantation, who was supported with a temporary extracorporeal ventricular assist device with the addition of an oxygenator. He developed hemoptysis that forced the cessation of anticoagulation exposing to increased thromboembolic risk. We discuss this distinct clinical scenario with no clearly defined solution and explore the risks and benefits of the different treatment options. [ABSTRACT FROM AUTHOR]

Background: Hepatic inflow clamping during hepatectomy introduces ischemia-reperfusion (I/R) injury, and many authors regard the addition of caval occlusion as adding increased risk. Ischemic preconditioning (IPC) is one of the protective strategies employed to reduce I/R injury in animal experiments and limited clinical series. The aim of the present study was to determine the impact of systematic adoption of IPC in patients undergoing complex hepatectomy under total hepatic vascular exclusion (TVE) based on outcomes review. Methods: The records of 93 patients who underwent major hepatectomy involving TVE at our center from February 1998 to December 2008 were reviewed. These patients were divided into two groups: group 1 ( n = 55, TVE alone) and group 2 ( n = 38, TVE with IPC). IPC was performed by portal triad clamping for 10 min followed by 3-5 min of reperfusion prior to TVE and resection. Results: The two groups were comparable regarding demographics, underlying liver diseases, indications for hepatectomy, duration of TVE, and preoperative liver and kidney function tests. Overall postoperative laboratory results of liver function tests were not significantly different between the two groups. Creatinine levels and prothrombin times were not significantly different between the groups. The use of IPC had no impact on the duration of the operation, blood loss, or hospital stay. The morbidity rates were 37.5 and 34.2 %, respectively. Conclusions: Our adoption of IPC as a protective strategy against I/R injury under TVE did not affect operative or laboratory parameters and clinical outcomes when compared to continuous clamping for comparable ischemic periods. [ABSTRACT FROM AUTHOR]

Service requirements of liver transplant anesthesia teams: society for the advancement of transplant anesthesia recommendations. Recommendations from the Society for the advancement of transplant anesthesiology: liver transplant anesthesiology fellowship core competencies and milestones. Keywords: anesthesiology; Professional Societies; transplantation EN anesthesiology Professional Societies transplantation 1 2 2 03/03/21 20210201 NES 210201 The Society for the Advancement of Transplant Anesthesia (SATA) looks forward to having Clinical Transplantation as its scholarly home. [Extracted from the article]