Search

Objectives: To explore the incidence, risk factors, and impact of elevated mean pulmonary artery pressure (mPAP) on 30-day mortality in liver transplantation (LT)., Design: A retrospective study., Setting: University tertiary medical center., Participants: Adult patients who underwent between 2013 and 2023., Intervention: No intervention., Measurements and Main Results: Data for consecutive adults who underwent LT (n = 1243) between 2013 and 2023 were extracted from our institutional Discovery Data Repository. Elevated mPAP was defined as ≥40 mmHg or a ≥20% increase from baseline during the first hour following reperfusion. The 30-day mortality rate was recorded. Risk factors were identified using multivariable logistic regression. The study cohort had a mean age of 55.2 ± 11.9 years and a mean model for end-stage liver disease sodium (MELD-Na) score of 34.8 ± 6.1. Ninety-one patients (7.3%) developed an elevated postreperfusion mPAP. Multivariable logistic regression revealed that preoperative elevated PAP estimated by echocardiogram, preoperative serum creatinine, and the use of epinephrine during LT were significant risk factors. Thirty-two patients (1.9%) died within 30 days after LT. Elevated postreperfusion mPAP was significantly associated with 30-day mortality (odds ratio, 6.056; 95% confidence interval, 2.349-15.611; p < 0.001)., Conclusions: mPAP is frequently elevated after graft reperfusion during LT, but its influence on clinical outcomes remains unclear. This retrospective study found a 7.3% rate of high PAP following reperfusion in LT, and high postreperfusion PAP was associated with 30-day mortality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Delayed graft function (DGF) is a common early complication after kidney transplantation (KT) and is associated with various long-term adverse outcomes. Despite numerous studies on hemodynamic management, the optimal hemodynamic goals during KT remain unclear. In this retrospective study, we aimed to investigate if three mean artery pressure (MAP) thresholds (≤75, 80, and 85 mmHg) that were commonly used in clinical practice were associated with DGF in adult patients undergoing KT., Methods: We extracted de-identified data on adult patients who underwent deceased donor KT from our Discovery Data Repository. DGF was defined as the requirement for dialysis within the first 7 days after transplantation. Three MAP thresholds (≤75, 80, and 85 mmHg) and the duration of pressure below the three thresholds were recorded. Multivariable logistic analysis was used to identify risk factors for DGF., Results: We included 2301 adult KT patients. The mean age was 52.5±12.9 years and 59% were male. DGF occurred in 1066 patients (46.3%). Patients frequently experienced MAP ≤75, 80, and 85 mmHg (approximately 70%, 80%, and 90% of patients experienced 10 min of MAP ≤75, 80, and 85 mmHg, respectively). Patients with DGF spent significantly longer durations below the three MAP thresholds during surgery compared with those without DGF. Further analysis revealed that the minimal time spent on MAP ≤75, 80, and 85 mmHg that were significantly associated with DGF were 6, 23, and 37 min, respectively. After adjusting for non-hemodynamic risk factors (age, basiliximab administration, and urine output), prolonged exposure to the three MAP thresholds remained significant predictors for DGF (for MAP ≤75 mmHg, OR 1.257, 95% CI 1.017-1.554, p = 0.034; MAP ≤80 mmHg, OR 1.220, 95% CI 1.018-1.463, p = 0.031; MAP ≤85 mmHg, OR 1.253, 95% CI 1.048-1.498, p = 0.013)., Conclusion: Prolonged exposure to the three common MAP thresholds (≤75, 80, and 85 mmHg) occurred frequently during adult deceased donor KT and was associated with DGF., (© 2024 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Preoperative risk assessment in liver transplant (LT) candidates, particularly related to cardiac risk, is an area of intense interest for transplant clinicians. Various cardiac testing methods are employed by transplant centers to characterize cardiac risk. Serum troponin is an established method for the detection of myocardial injury in a wide variety of clinical settings. Preoperative troponin screening has been reported to predict postoperative cardiac events and mortality in various surgical patient populations, however, the utility of preoperative troponin to predict posttransplant outcomes in current LT candidate populations requires further investigation., Methods: We performed a prospective blinded study in a cohort of 275 consecutive LT recipients at a single transplant center to determine if preoperative serum troponin I (TnI) was predictive for postoperative 1-year mortality., Results: Abnormal preoperative TnI levels (>.1 ng/mL) were found in 38 patients (14%). One-year mortality occurred in 19 patients (7%). There was no significant difference in mortality between patients with normal and abnormal troponin levels. Additionally, we found that there was no significant difference in early postoperative major adverse cardiac events between patient groups., Conclusions: Contrary to previous reports, elevated preoperative TnI was not significantly predictive of posttransplant mortality in LT recipients at our institution., (© 2023 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Massive hemorrhage and transfusion during liver transplantation (LT) present great challenges. We aimed to investigate the incidence and risk factors for super-massive transfusion (SMT) and survival outcome and factors that negatively affect survival in patients who received SMT during LT., Study Design and Methods: We included adult patients undergoing LT from 2004 to 2019. SMT was defined as transfusion of ≥50 units of red blood cells (RBC) during LT. Independent risk factors were identified by multivariable logistic regression. Ninety-day survival was recorded and factors that negatively affected survival were analyzed by the Cox survival test., Results: Of 2772 patients, 158 (5.6%) received SMT during LT. Mean RBC transfusion was 72.6 (±23.4) units with a maximum of 168 units. Four variables (MELD-Na score, previous upper abdominal surgery, portal vein thrombosis, and remote retransplant) were independent risk factors for SMT (odds ratio 1.800-8.274, 95% CI 1.008-16.685, all p < .005). The 90-day survival rate in SMT patients was 81.6%. Preoperative pulmonary hypertension and massive postreperfusion transfusion negatively affected 90-day survival (hazard ratio 2.658-4.633, 95% CI 1.144-10.130, and all p < .05)., Conclusions: In this large retrospective study, we found that SMT occurred in a small percentage of patients and was associated with relatively satisfactory short-term survival. Identification of preoperative risk factors for SMT and factors that negatively affect survival improve our understanding of this unique LT patient population., (© 2023 AABB.)

Objective: We aimed to identify preoperative and intraoperative factors associated with serious postoperative outcomes, which may help patients and clinicians make better-informed decisions., Methods: We conducted a retrospective study including all patients aged ≥90 years who underwent surgery between January 1, 2011, and January 1, 2021, at Chongqing University Central Hospital. We assessed 30 pre- and intraoperative demographic and clinical variables. Logistic regression was used to identify the independent risk factors for serious postoperative outcomes in patients aged ≥90 years., Results: A total of 428 patients were included in our analysis. The mean age was 92.6 years (SD ± 2.6). There were 240 (56.1%) females and 188 (43.9%) males. The most common comorbidities were hypertension (44.9%) and arrhythmias (34.8%). The 30-day hospital mortality was 5.6%, and severe morbidity was 33.2%. Based on the multivariate logistic regression classification analysis of the American Society of Anesthesiologists (ASA)≥ Ⅳ [odds ratio (OR), 5.39, 95% confidence interval (CI), 2.06-14.16, P = .001], emergency surgery (OR, 5.02, 95% CI, 2.85-15.98, P = .001) and chronic heart failure (OR, 6.11, 95% CI, 1.93-13.06, P = .001) were identified as independent risk factors for 30-day hospital mortality, and ASA≥ Ⅳ (OR, 4.56, 95%CI, 2.56-8.15, P < .001), Barthel index (BI) < 35 (OR, 2.28, 95%CI, 1.30-3.98, P = .001), chronic heart failure (OR, 3.67, 95%CI, 1.62-8.31, P = .002), chronic kidney disease (OR, 4.24, 95%CI, 1.99-9.05, P < .001), general anesthesia (OR, 3.31, 95%CI, 1.91-5.76, P < .001), emergency surgery (OR, 3.72, 95%CI, 1.98-6.99, P < .001), and major surgery (OR, 3.44, 95%CI, 1.90-6.22, P < .001) were identified as independent risk factors for serious postoperative complications., Conclusions: Patients aged ≥90 years with ASA≥ Ⅳ, BI < 35, combined with chronic heart failure or chronic kidney disease, undergoing emergency surgery, major surgery or general anesthesia have a higher risk of serious postoperative outcomes. Identifying these risk factors in an early stage may contribute to our clinical decision-making and improve the quality of treatments., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Intraoperative hypotension (IOH) is common and associated with mortality in major surgery. Although patients undergoing liver transplantation (LT) have low baseline blood pressure, the relation between blood pressure and mortality in LT is not well studied. We aimed to determine mean arterial pressure (MAP) that was associated with 30-d mortality in LT., Methods: We performed a retrospective cohort study. The data included patient demographics, pertinent preoperative and intraoperative variables, and MAP using various metrics and thresholds. The endpoint was 30-d mortality after LT., Results: One thousand one hundred seventy-eight patients from 2013 to 2020 were included. A majority of patients were exposed to IOH and many for a long period. Eighty-nine patients (7.6%) died within 30 d after LT. The unadjusted analysis showed that predicted mortality was associated with MAP <45 to 60 mm Hg but not MAP <65 mm Hg. The association between MAP and mortality was further tested using adjustment and various duration cutoffs. After adjustment, the shortest durations for MAPs <45, 50, and 55 mm Hg associated with 30-d mortality were 6, 10, and 25 min (odds ratio, 1.911, 1.812, and 1.772; 95% confidence interval, 1.100-3.320, 1.039-3.158, and 1.008-3.114; P  = 0.002, 0.036, and 0.047), respectively. Exposure to MAP <60 mm Hg up to 120 min was not associated with increased mortality., Conclusion: In this large retrospective study, we found IOH was common during LT. Intraoperative MAP <55 mm Hg was associated with increased 30-d mortality after LT, and the duration associated with postoperative mortality was shorter with lower MAP than with higher MAP., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2022 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Background: Mechanical ventilation plays an important role in perioperative management and patient outcomes. Although mechanical ventilation with high tidal volume (HTV) is injurious in patients in the intensive care unit, the effects of HTV ventilation in patients undergoing liver transplant (LT) has not been reported. The aim of this study was to determine if intraoperative HTV ventilation was associated with the development of acute respiratory distress syndrome (ARDS)., Methods: Patients undergoing LT between 2013 and 2018 at a tertiary medical center were reviewed. The tidal volume was recorded at 3 time points: after anesthesia induction, before liver reperfusion, and at the end of surgery. Patients were divided into 2 groups: HTV (>10 mL/kg predicted body weight [pBW]) and non-HTV (≤10 mL/kg pBW). The 2 groups were compared. Independent risk factors were identified by multivariable logistic models., Results: Of 780 LT patients, 85 (10.9%) received HTV ventilation. Female sex and greater difference between actual body weight and pBW were independent risk factors for HTV ventilation. Patients who received HTV ventilation had a significantly higher incidence of ARDS (10.3% vs 3.9%; P = .01) than those who received non-HTV ventilation., Conclusions: In this retrospective study, we showed that HTV ventilation during LT was common and was associated with a higher incidence of ARDS. Therefore, tidal volume should be carefully selected during LT surgery. More studies using a prospective randomized controlled design are needed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Takotsubo syndrome (TTS) can develop after liver transplant (LT), but its predisposing factors are poorly understood. In this study, we aimed to determine if perioperative factors were associated with posttransplant TTS. Adult patients who underwent primary LT between 2006 and 2018 were included. Patients with and without TTS were identified and matched by propensity scores. Of 2181 LT patients, 38 developed postoperative TTS with a mean left ventricular ejection fraction of 25.5% (±7.8%). Multivariable logistic regression revealed two preoperative risk factors (alcoholic cirrhosis and model for end-stage liver disease-sodium scores) for TTS. Post-propensity match analyses showed that TTS patients had significantly higher doses of epinephrine and lower doses of fentanyl during LT compared with non-TTS patients. A higher dose of epinephrine and a lower dose of fentanyl was associated with a higher predicted probability of TTS. All TTS patients had full recovery of cardiac function and had comparable 1-year survival. In conclusion, TTS occurred at a rate of 1.7% after LT and was associated with two pretransplant risk factors. The higher doses of epinephrine and lower doses of fentanyl administered during LT were associated with posttransplant TTS. More studies on the relationship between intraoperative medications and TTS are warranted., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

BACKGROUND The Share 35 policy was introduced in 2013 by the Organ Procurement and Transplantation Network (OPTN) to increase opportunities of sicker patients to access liver transplantation. However, it has the disadvantage of higher MELD score associated with adverse postoperative transplant outcomes. Early data after implementation of the Share 35 policy showed significantly poorer post-transplantation survival in some UNOS regions. We aimed to analyze the impact of Share 35 on demographics of patients, perioperative management, and perioperative mortality. MATERIAL AND METHODS A retrospective analysis of data was performed from an institutional liver transplantation cohort from 1 January 2008 to 31 December 2017. Adult patients who underwent liver transplantation before 2013 were defined as the pre-Share 35 group and the other group was defined as the post-Share 35 group. The MELD score of each patient was calculated at the time of transplantation. Perioperative mortality was defined as death within 30 days after the operation. RESULTS A total of 1596 patients underwent liver transplantation. Of those, 895 recipients underwent OLT in the pre-Share 35 era and 737 in the post-Share 35 era. The median MELD score was significantly higher in the post-Share 35 group (30 vs 26, P<0.001) and 45.7% of the post-Share 35 group had MELD scores ≥35. In intraoperative management, patients required significantly more blood component transfusion, intraoperative vasopressor, and fluid replacement. Veno-venous bypass (VVB) usage was significantly higher in the post-Share 35 era (47.2% vs 38.1%, P<0.001). In the subgroup of patients with MELD scores ≥35, the median waiting time was significantly shorter (18.5 vs 14.5 days, P=0.045). Overall perioperative mortality was not significantly difference between groups (P=0.435). CONCLUSIONS After implementation of the Share 35 policy, we performed liver transplantation in significantly higher medical acuity patients, which required more medical resources to obtain a result comparable to that of the pre-Share 35 era.

Background: Although hemorrhage is a major concern during liver transplantation (LT), the risk for thromboembolism is well recognized. Implementation of rotational thromboelastometry (ROTEM) has been associated with the increased use of cryoprecipitate; however, the role of ROTEM-guided transfusion strategy and cryoprecipitate administration in the development of major thromboembolic complications (MTCs) has never been documented., Methods: We conducted a study on patients undergoing LT before and after the implementation of ROTEM. We defined MTC as intracardiac thrombus, pulmonary embolism, hepatic artery thrombosis, and ischemic stroke in 30 d after LT. We used a propensity score to match patients during the 2 study periods., Results: Among 2330 patients, 119 (4.9%) developed MTC. The implementation of ROTEM was significantly associated with an increase in cryoprecipitate use (1.1 ± 1.1 versus 2.9 ± 2.3 units, P < 0.001) and MTC (4.2% versus 9.5%, P < 0.001). Further analysis demonstrated that the use of cryoprecipitate was an independent risk factor for MTC (odds ratio 1.1, 95% confidence interval 1.04-1.24, P = 0.003). Patients with MTC had significantly lower 1-y survival., Conclusions: Our study suggests that the implementation of ROTEM and the use of cryoprecipitate play significant roles in the development of MTC in LT. The benefits and risks of cryoprecipitate transfusion should be carefully evaluated before administration., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Combined cardiothoracic surgery and liver transplantation (cCSLT) recently increasingly has been used. Despite that, liver transplant immediately after cardiothoracic surgery has not been well-characterized. The authors aimed to compare perioperative management and postoperative outcomes between patients undergoing cCSLT and isolated liver transplantation (iLT)., Design: A retrospective study., Setting: University tertiary medical center., Participants: Twenty-five cCSLT patients and 1091 iLT patients at a single institution from 2010 to 2017., Interventions: Twenty-five cCSLT patients were compared with 100 randomly selected and 100 propensity-matched iLT patients., Measurements and Main Results: All cCSLT patients underwent comprehensive preoperative evaluation by a multidisciplinary team. Of 25 cardiothoracic surgeries, heart transplant (n = 9) was most common, followed by coronary artery bypass grafting (n = 5) and lung transplant (n = 3). Intraoperative management of cCSLT was provided by 2 separate teams, one for cardiothoracic surgery and one for liver transplantation. Patients undergoing cCSLT often required cardiopulmonary bypass, an intra-aortic balloon pump, extracorporeal membrane oxygenation, or cardiac pharmacologic therapies and, additionally, needed more interventions including antifibrinolytic administration, venovenous bypass, massive blood transfusion, and platelet transfusions compared with iLT patients. Ninety-day survival rates were similar in the cCSLT (100%) and iLT groups (random iLT 87% and matched iLT 93%, log-rank test p = 0.089)., Conclusions: Despite having end-stage liver disease and advanced cardiothoracic disorders and experiencing a complex intraoperative course, cCSLT patients had comparable 90-day survival to iLT patients. Comprehensive planning before transplant, optimal patient/donor selection, the multiple-team model, and meticulous intraoperative management are critical to the success of cCSLT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: The authors declare no funding or conflicts of interest.

Pretransplant left ventricular hypertrophy (LVH) is a common finding during preoperative cardiac evaluation. We hypothesized that patients with pretransplant LVH were associated with a higher risk of postoperative myocardial injury (PMI) in adult patients undergoing liver transplantation (LT). A retrospective cohort analysis was performed by reviewing the medical records of adult patients who underwent LT between January 2006 and October 2013. Of 893 patients, the incidences of mild, moderate, and severe LVH were 7.8%, 5.6%, and 2.5%, respectively. Propensity match was used to eliminate the pretransplant imbalance between the LVH and non-LVH groups. In after-match patients, 23.5% of LVH patients developed PMI compared to 11.8% in the control group (P = .011). The incidence of PMI in patients with moderate-severe degrees of LVH was significantly higher compared with that in patients with mild LVH (27.9% vs 19.1%, P = .016). When controlling intraoperative variables, patients with LVH had 4.5 higher odds of developing PMI (95% CI1.18-17.19, P = .028). Patients experiencing PMI had significantly higher 1-year mortality (37.5% vs 15.7%, log-rank test P < .001). Our results suggest that patients with pretransplant LVH were at a high risk of developing PMI and should be monitored closely in the perioperative period. More studies are warranted., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Venovenous bypass (VVB) is a technique that was developed in the 1980s to mitigate untoward hemodynamic effects of complete cross-clamping of the inferior vena cava during liver transplantation (LT). Since the introduction of nonclassic surgical techniques, the interest in using VVB has decreased. Despite this, VVB is still commonly practiced today. In the last 2 decades, significant changes have been made in many aspects of LT. New developments in VVB have been also reported. A percutaneous technique appears safer and easier to perform compared with the surgical cut-down method. Recent data suggest that patients with high acuity may benefit more from VVB. Advances in extracorporeal technologies offer new opportunities for VVB in managing critically ill patients in LT. Here, we review these new developments in VVB., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Intracranial hemorrhage (ICH) is a devastating complication. Although hypertension and thrombocytopenia are well-known risk factors for ICH in the general population, their roles in ICH after liver transplantation (LT) have not been well established., Methods: We performed a retrospective study and hypothesized that intraoperative hypertension and thrombocytopenia were associated with posttransplant ICH. New onset of spontaneous hemorrhage in the central nervous system within 30 days after LT were identified by reviewing radiologic reports and medical records. Risk factors were identified by multivariate logistic regression. Receiver operating characteristic analysis and Youden index were used to find the cutoff value with optimal sensitivity and specificity., Results: Of 1836 adult patients undergoing LT at University of California, Los Angeles, 36 (2.0%) developed ICH within 30 days after LT. Multivariate logistic regression demonstrated that intraoperative mean arterial pressure ≥105 mm Hg (≥10 min) (odds ratio, 6.5; 95% confidence interval, 2.7-7.7; P < 0.001) and platelet counts ≤30 × 10/L (odds ratio, 3.3; 95% confidence interval, 14-7.7; P = 0.006) were associated with increased risk of postoperative ICH. Preoperative total bilirubin ≥7 mg/dL was also a risk factor. Thirty-day mortality in ICH patients was 48.3%, significantly higher compared with the non-ICH group (3.0%; P < 0.001). Patients with all 3 risk factors had a 16% chance of developing ICH., Conclusions: In the current study, postoperative ICH was uncommon but associated with high mortality. Prolonged intraoperative hypertension and severe thrombocytopenia were associated with postoperative ICH. More studies are warranted to confirm our findings and develop a strategy to prevent this devastating posttransplant complication.

Aim: To understand the risk perceptions, behaviour, attitudes, and experiences related to smoking among hospitalized Chinese smokers., Background: Understanding hospitalized smokers' perceptions of risks associated with smoking, along with their behaviour, attitudes, and smoking-related experiences, is essential prerequisite to design effective interventions to help them quit smoking., Design: A phenomenological research design was adopted., Methods: A purposive sampling approach was used. Between May 2016-January 2017, 30 hospitalized smokers were invited for an interview., Results: Four themes were generated: (a) associations between perception of illness and smoking; (b) perceived support from healthcare professionals to quit smoking; (c) impact of hospitalization on behaviour, attitudes, and experiences; and (d) perceived barriers to quitting smoking., Conclusion: Development of an innovative intervention that helps to demystify misconceptions about smoking through brief interventions and active referrals is recommended to enhance the effectiveness of healthcare professionals promoting smoking cessation for hospitalized smokers., Impact: To date, no study examining smoking behaviour among hospitalized patients in Hong Kong has been conducted. Misconceptions about smoking and health, barriers to quitting that outweighed perceived benefits, lack of support from healthcare professionals, and difficulty overcoming withdrawal symptoms or cigarette cravings precluded hospitalized smokers sustaining smoking abstinence after discharge. Smoking is detrimental to physical health. Smoking cessation has beneficial effects on treatment efficacy and prognosis and helps to reduce the economic burden on society from smoking-attributable diseases., (© 2019 John Wiley & Sons Ltd.)

Background: Mild left ventricular systolic dysfunction (LVSD) is common in patients waiting for liver transplantation (LT), but its impact on intraoperative management and survival is poorly understood. In this study, we investigated if mild pretransplant LVSD was associated with the use of intraoperative vasopressors and 1-year survival after LT., Methods: After institutional review board approval, preoperative echocardiographic and perioperative data of adult patients undergoing LT between January 2006 and October 2013 were reviewed. Patients with or without mild LVSD were compared using the t test or Pearson's χ 2 test. Independent risk factors were identified using multivariate logistic regression., Results: Of 1055 adult patients, 11 (1.0%) had mild LVSD. Preoperative variables were similar between the 2 groups except for age and preoperative vasopressor use. Intraoperatively, a greater portion of patients with LVSD required vasopressors following anesthesia induction (71.4% vs 20.5%), immediately after reperfusion (100% vs 62.1%), and at the end of the transplant (100% vs 38.5%) compared with patients without LVSD (all P < .05). Multivariate logistic analysis showed that LVSD was an independent risk factor (odds ratio, 4.7; 95% CI 1.0-21.3; P = .043) for increased requirement of intraoperative vasopressor along with other risk factors, including encephalopathy, preoperative pressors, male sex, high model for end-stage liver disease score, and long cold ischemia time. Patients with mild LVSD had similar 1-year survival rates compared with non-LVSD patients., Conclusions: Patients with mild preoperative LVSD, with proper intraoperative management, could undergo LT surgery and had comparable 1-year survival. Patients with mild preoperative LVSD alone should not be excluded from LT., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Nonselective Beta blockade (NSBB) is commonly prescribed for liver transplantation (LT) candidates, but its impact on intraoperative hemodynamics is not well understood. In this study, we investigated if preoperative NSBB was associated with severe bradycardia during LT and if severe intraoperative bradycardia was associated with 30-day mortality. Adult patients undergoing LT between 2005 and 2014 were included. Propensity matching was used to control selection bias. Intraoperative hemodynamics were compared between patients with and without preoperative NSBB. Univariate and multivariate methods were used in statistical analysis. Of 1452 patients, 370 who received preoperative NSBB were matched in a 1:1 ratio with those who did not. Propensity matching eliminated all significant differences between the two groups. Patients who received preoperative NSBB had a significantly higher incidence of severe intraoperative bradycardia compared with the non-BB group (9.6% vs 3.2%, P = 0.001, OR 2.95, 95% CI 1.42-6.12, P = 0.004). Intraoperative hypotension and postreperfusion syndrome were not significantly different between the two groups. Severe intraoperative bradycardia was associated with increased 30-day mortality. In conclusion, preoperative NSBB was associated with severe intraoperative bradycardia in LT. In patients who receive preoperative NSBB, severe intraoperative bradycardia should be closely monitored in LT. Further studies assessing safety of preoperative NSBB and intraoperative bradycardia in LT are warranted., (© 2018 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objectives: The water-associated attributes of resin-dentin interfaces created by contemporary adhesives are important determinants of bond integrity and stability. In the present work, these attributes were estimated from the perspectives of causality, to examine the behavior of the first and most-recently launched versions of universal adhesives when applied in either the etch-and-rinse mode or the self-etch mode., Methods: The immediate cause of interfacial permeability and the time-dependent cause of water sorption were investigated in conjunction with the intermediate effect of interface degradation and the more long-term effect of loss of mechanical strength, before and after thermomechanical cycling. The results were compared with control etch-and-rinse and self-etch adhesives., Results: Although the introduction of this new class of universal adhesives has brought forth significant changes to the dental adhesion arena, including more application options, reduced bonding armamentarium and increased user friendliness, the water-associated attributes that are critical for making resin-dentin bonds more durable to environmental challenges and less susceptible to degradation have remained unchanged at large, when compared with benchmarks established by former classes of adhesives., Conclusion: It appears that the current trend of adhesive development has brought forth significant changes but lacks the vigor that demarcates progress and technological sublimity., Clinical Significance: The advent of the user friendly universal adhesives has brought forth significant changes to the dental adhesion arena. However, the elements that are critical for making resin-dentin bonds more durable to environmental challenges and less susceptible to degradation have remained unchanged at large., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Aims and Objectives: To explore the relationship between smoking and other risk behaviours among Chinese young people in Hong Kong., Background: There is growing concern about coexisting risk behaviours in young smokers. Information about smoking and other risk behaviours is crucial for developing interventions to promote smoking abstinence and adoption of healthy lifestyles. The relationship between smoking and other risk behaviours among Chinese young people in Hong Kong has not been explored., Design: This is a mixed-method retrospective population-based study., Methods: A retrospective population-based study was conducted with 1,147 young smokers through Youth Quitline between November 2011-July 2016. Attitudes, behaviours and experiences related to smoking and risk behaviours among Chinese young smokers were examined in semi-structured qualitative interviews with 30 participants randomly selected from the retrospective population-based study., Results: In total, 45.5% participants reported engaging in at least one other risk behaviour. The interviews revealed that drinking alcohol may have a significant impact on quitting smoking. In addition, smoking may be a gateway for more serious risk behaviours during adolescence. Low health awareness may explain the unhealthy lifestyles among young smokers., Conclusions: This study bridges a gap in existing literature by exploring relationships between smoking and other risk behaviours among young people in Hong Kong., Relevance to Clinical Practice: Given the interrelationships between smoking and other risk behaviours, a holistic approach should be used to promote smoking cessation and healthy lifestyles among young smokers. If young smokers improve their health and quit smoking at the same time, their physical and mental development will benefit as a secondary outcome., (© 2018 John Wiley & Sons Ltd.)

Background: Although the hemodynamic benefits of venovenous bypass (VVB) during liver transplantation (LT) are well appreciated, the impact of VVB on posttransplant renal function is uncertain. The aim of this study was to determine if VVB was associated with a lower incidence of posttransplant acute kidney injury (AKI)., Methods: Medical records of adult (≥18 years) patients who underwent primary LT between 2004 and 2014 at a tertiary hospital were reviewed. Patients who required pretransplant renal replacement therapy and intraoperative piggyback technique were excluded. Patients were divided into 2 groups, VVB and non-VVB. AKI, determined by the Acute Kidney Injury Network criteria, was compared between the 2 groups. Propensity match was used to control selection bias that occurred before VVB and multivariable logistic regression was used to control confounding factors during and after VVB., Results: Of 1037 adult patients who met the study inclusion criteria, 247 (23.8%) received VVB. A total of 442 patients (221 patients in each group) were matched. Aftermatch patients were further divided according to a predicted probability AKI model using preoperative creatinine (Cr), VVB, and intraoperative variables into 2 subgroups: normal and compromised pretransplant renal functions. In patients with compromised pretransplant renal function (Cr ≥1.2 mg/dL), the incidence of AKI was significantly lower in the VVB group compared with the non-VVB group (37.2% vs 50.8%; P = .033). VVB was an independent risk factor negatively associated with AKI (odds ratio, 0.1; 95% confidence interval, 0.1-0.4; P = .001). Renal replacement in 30 days and 1-year recipient mortality were not significantly different between the 2 groups. The incidence of posttransplant AKI was not significantly different between the 2 groups in patients with normal pretransplant renal function (Cr <1.2 mg/dL)., Conclusions: In this large retrospective study, we demonstrated that utilization of intraoperative VVB was associated with a significantly lower incidence of posttransplant AKI in patients with compromised pretransplant renal function. Further studies to assess the role of intraoperative VVB in posttransplant AKI are warranted.

The shortage of suitable organs is the biggest obstacle for transplants. At present, most organs for transplant in the United States are from donation after neurologic determination of death (brain death). Potential organs for transplant need to maintain their viability during a series of insults, including the original disease, physiologic derangements during the dying process, ischemia, and reperfusion. Proper donor management before, during, and after procurement has potential to increase the number and quality of organs from donors. Anesthesiologists need to understand the physiologic derangements associated with brain death and the updated donor management during the periprocurement period., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Myocardial injury, defined as an elevation of cardiac troponin (cTn) resulting from ischemia, is associated with substantial mortality in surgical patients, and its incidence, risk factors, and impact on patients undergoing liver transplantation (LT) are poorly understood. In this study, adult patients who experienced perioperative hemodynamic derangements and had cTn measurements within 30 days after LT between 2006 and 2013 were studied. Of 502 patients, 203 (40.4%) met the diagnostic criteria (cTn I ≥0.1 ng/mL) of myocardial injury. The majority of myocardial injury occurred within the first three postoperative days and presented without clinical signs or symptoms of myocardial infarction. Thirty-day mortality in patients with myocardial injury was 11.4%, significantly higher compared with that in patients without myocardial injury (3.4%, P<.01). Cox analysis indicated the peak cTn was significantly associated with 30-day mortality. Multivariable logistic analysis identified three independent risk factors: requirement of ventilation before transplant (odds ratios (OR) 1.6, P=.006), RBC≥15 units (OR 1.7, P=.006), and the presence of PRS (OR 2.0, P=.028). We concluded that post-LT myocardial injury in this high-risk population was common and associated with mortality. Our findings may be used in pretransplant stratification. Further studies to investigate this postoperative cardiac complication in all LT patients are warranted., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Purpose: Acute respiratory distress syndrome (ARDS) is a devastating complication with substantial mortality. The aims of this study were to identify the incidence, preoperative and intraoperative risk factors, and impact of ARDS on outcomes in patients after orthotopic liver transplantation (OLT)., Materials and Methods: Adult OLT patients between January 2004 and October 2013 at our center were included. Postoperative ARDS was determined using the criteria proposed by the Berlin Definition. Multivariate logistic models were used to identify preoperative and intraoperative risk factors for ARDS., Results: Of 1726 patients during the study period, 71 (4.1%) developed ARDS. In the preoperative model, encephalopathy (odds ratio [OR], 2.22; P = .022), preoperative requirement of intubation (OR, 2.06; P = .020), and total bilirubin (OR, 1.02; P = .003) were independent risk factors. In the intraoperative model, large pressor bolus was the sole risk factor for ARDS (OR, 2.69; P = .001). Postoperatively, patients with ARDS had a 2-fold increase in 1-year mortality, mechanical ventilation time, and length of hospital stay., Conclusions: Acute respiratory distress syndrome occurred at a rate of 4.1% following OLT in adult patients and was associated with preoperative encephalopathy, requirement of intubation, and total bilirubin and intraoperative large boluses of pressors. Acute respiratory distress syndrome was associated with increased mortality, longer ventilation time, and hospital stay., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Although female patients are associated with several complications after liver transplantation (OLT), its role in short-term postoperative outcomes is not known. The aims of this study were to investigate the relationship between female gender and ventilation time and hospital stay after OLT., Methods: After receiving institutional review board approval, we studied adult patients who underwent OLT at our center between 2004 and 2013. Female and male recipients were compared by using Student t and χ(2) tests. Risk factors were confirmed in multivariate logistic models., Results: Of 1476 patients, 490 were female. Compared with male counterparts, female recipients had more severe disease and comorbidities. Intraoperatively, the 2 groups were similar except for blood transfusion. Postoperatively, female recipients required significantly longer ventilation time (median, 3 days [interquartile range (IQR), 2-5], vs median, 2 [IQR, 1-5]; P = .009) and duration of hospital stay (median, 23 [IQR, 15-46] vs median, 18 [IQR, 12-34]; P < .001) compared with male recipients. Female gender was an independent risk factor for prolonged posttransplant ventilation time (≥3 days; odds ratio [OR], 1.65; P < .001) and hospital stay (≥19 days; OR, 1.48; P = .003)., Conclusions: Female gender of the recipient is associated with significantly longer ventilation time and hospital stay after OLT and the management should be tailored to the unique characteristics and susceptibility to postoperative complications in female patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Although intestine-inclusive liver transplantation (IILT) is performed regularly, its perioperative management has not been studied extensively., Methods: Patients who underwent IILT and isolated liver transplantation (LT) at our center from January 2006 to December 2012 were identified. Among >1,000 LT patients, 90 were selected after matching by age, sex, surgery date, and status of preoperative ventilation for comparison with 45 IILT patients., Results: There were no significant differences regarding preoperative variables between the 2 groups except for international normalized ratio. However, IILT patients had significantly higher intraoperative requirement of blood transfusion, incidences of post-reperfusion syndrome, and hyperkalemia compared with LT patients. Postoperatively, IILT patients had significantly longer hospital stay and higher 1-year mortality. Multivariate analysis indicated that IILT was a primary risk factor associated with the studied complications and adverse outcomes., Conclusions: Our findings suggest that, compared with LT patients, IILT patients were more prone to develop intraoperative complications and adverse outcomes and should be closely monitored and aggressively managed., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Postoperative atrial fibrillation (POAF) is common after major surgeries and is associated with increased morbidity and mortality. POAF after liver transplantation (LT) has not been reported. This study was undertaken to investigate the incidence, impact, and risk factors of POAF in LT patients. After IRB approval, LT between January 2006 and August 2013 at our center were retrospectively reviewed. POAF that occurred within 30 days after LT was included. Patients with and without POAF were compared and independent risk factors were identified by logistic regression. Of 1387 adults LT patients, 102 (7.4%) developed POAF during the study period. POAF was associated with significantly increased mortality, graft failure, acute kidney injury and prolonged hospital stay. Independent risk factors included age, body weight, MELD score, presence of previous history of AF, the vasopressors use prior to LT and pulmonary artery diastolic pressure at the end of LT surgery (odds ratios 2.0-7.2, all p < 0.05). A risk index of POAF was developed and patients with the high-risk index had more than 60% chance of developing POAF. These findings may be used to stratify patients and to guide prophylaxis for POAF in the posttransplant period., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objective: To investigate major gastroesophageal and hemorrhagic complications that may be related to intraoperative transesophageal echocardiography (TEE) in liver transplant (LT) patients with high model for end-stage liver disease (MELD) score 25 or higher., Design: Retrospective., Setting: Single institution university setting., Participants: Of 906 transplant recipients, 656 who had MELD score 25 or higher were included for analysis., Interventions: Patient demographics, pre- and intraoperative characteristics, and major gastroesophageal and hemorrhagic complications were compared between patients with and without TEE., Measurements and Main Results: Sixty-six percent (433 patients) had intraoperative TEE and 34% (223 patients) did not. One patient in the TEE group had a major gastroesophageal complication (Mallory-Weiss tear). Eleven patients required postoperative gastrointestinal consultation. These patients were distributed evenly between the TEE and non-TEE groups. Eighteen (2.8%) had major hemorrhagic complication (defined as bloody nasogastric output>500 mL in 24 hours postoperatively). Multivariate analysis showed alcoholic cirrhosis had 5.3 higher odds of post-transplant gastroesophageal hemorrhage compared with other indications for transplant (95% confidence interval 1.8-15.8, p<0.001). TEE was not associated with an increased likelihood of major hemorrhagic complication after LT., Conclusions: The authors demonstrated that the incidence of major gastroesophageal and hemorrhagic complications following intraoperative TEE in LT patients with MELD score 25 or higher was low., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Donation after cardiac death (DCD) is an important source for expanding the donor pool for liver transplantation (LT). Although the long-term outcomes of LT using DCD grafts have been extensively studied, perioperative complications related to DCD grafts are rarely reported. The aim of this study was to determine whether DCD grafts were associated with a higher incidence of postreperfusion complications and worse outcomes in adult LT patients. After institutional review board approval, the medical records of all adult patients who underwent LT at our medical center between 2004 and 2011 were reviewed. Postreperfusion complications and posttransplant outcomes were compared between patients receiving DCD grafts and patients receiving donation after brain death (DBD) grafts. In all, 74 patients received DCD grafts during the study period, and 1369 patients received DBD grafts. An initial comparison showed that many preoperative, prereperfusion, and donor variables in the DCD group differed significantly from those in the DBD group. Propensity matching was chosen so that adjustments could be made for the differences. A postmatching analysis showed that the preoperative, prereperfusion, and donor variables no longer differed between the 2 groups. The postreperfusion requirements for blood products and vasopressors, the posttransplant ventilation times, the incidence of posttransplant acute renal injury, and the 30-day and 1-year patient and graft survival rates were comparable between the 2 groups. However, patients receiving DCD grafts experienced significantly higher rates of hyperkalemia (33.8% versus 18.9%, P < 0.05) and postreperfusion syndrome (PRS; 25.7% versus 12.3%, P < 0.05). In conclusion, after adjustments for preoperative and prereperfusion risks via propensity matching, DCD grafts remained a risk factor for postreperfusion hyperkalemia and PRS. A prophylactic regimen aimed at decreasing postreperfusion hyperkalemia and PRS is recommended for the management of LT using DCD grafts., (© 2014 American Association for the Study of Liver Diseases.)

Background: Alterations in the central nervous system in patients with acute liver failure (ALF) present unique challenges in the perioperative period. In this retrospective study, we examined pretransplant neurological presentation and the incidence, clinical presentation, and risk factors associated with severe posttransplant brain injury (BI) in ALF patients undergoing orthotopic liver transplantation (OLT)., Methods: After institutional review board approval, ALF patients who underwent OLT between 2004 and 2010 at our center were reviewed. Pretransplant neurological presentation and severe posttransplant BI were examined. Risk factors for the latter were identified., Results: During the study period, 90 (67 adults and 23 children) ALF patients underwent primary OLT. Preoperatively, all patients developed encephalopathy, 6 had seizure activity, 32 had radiological evidence of cerebral edema, and 11 had severe cerebral edema. After OLT, 7 patients developed severe posttransplant BI. Of these 7 patients, 4 had brain death, and 3 had irreversible injury that precluded them from living independently. Severe pretransplant cerebral edema and a higher posttransplant international normalized ratio (odds ratios and 95% confidence intervals: 50.2, 5.8-433.5 [P<0.001] and 3.1, 1.1-8.8 [P=0.031], respectively) were risk factors associated with severe posttransplant BI., Conclusions: Pretransplant neurological complications were prevalent, and severe posttransplant BI occurred at a rate of 7.8% and was significantly associated with severe pretransplant cerebral edema and postoperative international normalized ratio. Our findings support the use of pretransplant computed tomography. If severe pretransplant cerebral edema is confirmed, efforts should be made to aggressively control intracranial pressure and select a proper donor to minimize the risk of severe posttransplant BI and futile transplantation.

Background: Recent studies suggest that the storage age of red blood cells (RBCs) may be associated with morbidity and mortality in surgical patients. We studied perioperative effects of RBC storage age in patients undergoing orthotopic liver transplant (OLT)., Methods: Adult patients who received ≥ 5 U of RBCs during OLT between January 2004 and June 2009 were studied. The subjects were divided into two groups according to the mean storage age of RBCs they received: new or old RBCs (stored ≤ 14 or >14 days, respectively). Effects of storage age of transfused RBCs during OLT on intraoperative potassium (K(+)) concentrations, incidence of hyperkalemia (K(+) ≥ 5.5 mmol/L), postoperative morbidity, and patient and graft survival were studied., Results: The mean serum K(+) concentrations and the incidence of hyperkalemia during OLT were significantly associated with storage age of the RBCs. Logistic analysis showed that storage age of RBCs was an independent risk factor for intraoperative hyperkalemia (odds ratios 1.067-1.085, p < 0.001) in addition to baseline K(+) concentration and units of RBCs transfused. Patient and graft survival and postoperative morbidity including postoperative ventilation, reoperation, acute renal dysfunction defined by the RIFLE criteria was not associated with old RBCs., Conclusions: Transfusion of RBCs stored for a longer time was associated with intraoperative hyperkalemia but not with postoperative adverse outcomes in adult OLT. Prevention and treatment of potentially harmful hyperkalemia should be considered when old RBCs are administered.

Objective: To define a prognostic scoring system for risk stratification of patients undergoing orthotopic liver transplantation (OLT) using grafts from donation after cardiac death (DCD)., Design: Retrospective study., Setting: University transplant center., Patients: Eighty-one patients underwent OLT using DCD grafts from March 1, 1994, to November 30, 2010. The mean follow-up was 2 years. Independent risk factors for graft failure after OLT were identified using Cox model and assigned risk score points. Points were summed and assigned to predictive index categories: 0 or 1 for low risk, 2 to 4 for intermediate risk, and 5 to 9 for high risk., Results: Six multivariate factors predictive for graft failure after OLT using DCD grafts included the following: for recipients, (1) diagnosis of hepatitis C virus with malignancy, non-hepatitis C virus with malignancy, or hepatitis C virus only, (2) previous OLT, and (3) body mass index (calculated as weight in kilograms divided by height in meters squared) greater than 30; for donors, (4) hepatitis B core antibody positivity and (5) mean arterial pressure lower than 60 mm Hg for longer than 20 minutes after withdrawal of life support; and for grafts, (6) cold ischemia time longer than 6 hours. Five-year graft failure-free survival was significantly higher for the low-risk group (83%) compared with the intermediate-risk (62%) and high-risk (0%) groups (P < .001). Overall biliary complications occurred in 24 patients (29%), with ischemic cholangiopathy in 8 patients (9.9%)., Conclusions: Our study showed superior long-term patient survival with liver transplantation using DCD organs in highly selected donors and recipients. We propose a practical risk stratification system highly predictive of long-term survival outcomes after OLT using DCD grafts. Application of this predictive index for transplant candidates receiving DCD liver grafts would improve patients' outcomes and optimize use of scarce resources.

Background: Acute renal injury (ARI) and acute renal failure (ARF) are serious complications after liver transplantation (LT). Few studies apply the risk, injury, function, loss, and end-stage criteria on the patients who have normal preoperative renal function. The aims of this study were to identify the incidence, risk factors, and impact of ARI and ARF in this patient population., Methods: After institutional review board approval, adult LT patients who had preoperative serum creatinine less than or equal to 1.5mmol/L were reviewed. Postoperative ARI and ARF were determined by the risk, injury, function, loss, and end-stage criteria. Risk factors were determined by multivariable regression. Postoperative outcomes were compared among patients with or without ARI or ARF., Results: Among 334 patients included the study, 20.4% and 18.0% had ARI or ARF in the first week after LT, respectively. Then 118 ARI or ARF patients were matched with patients without post-LT renal injury by gender, creatinine, and body mass index. Multivariable analysis showed that increased requirement of red blood cell transfusion (odds ratio [OR] 2.7-8.8, P<0.05), vasopressors (OR 2.2, P=0.018), and pre-LT albumin less than or equal to 3.5 mg/dL (OR: 2.8, P=0.003) as risk factors for post-LT ARI or ARF. Both ARI and ARF were associated with longer hospital stay and higher reoperation rate. ARF, but not ARI, was associated with higher 30-day graft failure and mortality rates., Conclusion: Post-LT ARI or ARF occurred frequently in patients with normal preoperative renal function and was associated with both preoperative and intraoperative risk factors. Although both post-LT ARI and ARF are associated with significant post-LT morbidity, the impact of ARF is greater.

Even though numerous cases of massive thromboemboli have been reported in the literature, intracardiac thromboemboli (ICTs) incidentally found during orthotopic liver transplantation (OLT) have not been examined. In this study, we retrospectively examined the incidence, risk factors, and management of incidental ICTs during OLT. After institutional review board approval, adult patients who underwent OLT between January 2004 and December 2008 at our center were reviewed. ICTs were identified and confirmed by the examination of OLT datasheets, anesthesia records, and recorded transesophageal echocardiography (TEE) clips. The clinical presentation, management, and outcomes of the patients with ICTs were reviewed. Risk factors were analyzed by multivariate logistic regression. During the study period, 426 of the 936 adult OLT patients (45.5%) underwent intraoperative TEE monitoring. Incidental ICTs were identified in 8 of these 426 patients (1.9%). Two ICTs occurred before reperfusion, and 6 ICTs occurred after reperfusion. The treatment was at the discretion of the treating physicians; however, none of the patients received an anticoagulant or thrombolytics. Multivariate analysis identified 2 independent risk factors for intraoperative incidental ICTs: the presence of symptomatic or surgically treated portal hypertension (a history of gastrointestinal bleeding, a transjugular intrahepatic portosystemic shunt procedure, or portocaval shunt surgery) before OLT and intraoperative hemodialysis (odds ratios of 4.05 and 7.29, respectively; P < 0.05 for both). In conclusion, incidental ICTs during OLT occurred at a rate of 1.9% and were associated with several preoperative and intraoperative risk factors. The use of TEE allows early identification, which may be important. Our management for incidental ICTs is described; however, no conclusions can be made about the optimal therapy., (Copyright © 2010 American Association for the Study of Liver Diseases.)

Reoperations for hemorrhage following liver transplantation (OLT) are commonly associated with increased morbidity and mortality. We sought to determine the incidence and risk factors for reoperation for hemorrhage among adult liver transplantations. We retrospectively analyzed 668 patients transplanted between January 2004 and November 2007. Within 30 days following transplantation one hundred eleven patients (16.6%) underwent 156 reoperations for hemorrhage, averaging 1.4 reoperations per patient. More than half of the reoperations occurred during the first 2 postoperative days. One-third of patients required 2 or more reoperations. Multivariate logistic regression analysis showed 4 independent risk factors: grafts from donors with multiple extended criteria, severe intraoperative glucose variability, intraoperative use of vasopressors, and red blood cell transfusion requirement. In conclusion, we identified several independent risk factors for reoperation due to hemorrhage following OLT. Avoidance of severe intraoperative glucose variability and careful evaluation of the benefits and risks of utilizing extended criteria donors must be considered before transplantation.

Objective: To assess the effectiveness of an insulin regimen in divided doses designed to target risk factors of hyperkalemia in patients undergoing liver transplantation., Design: Retrospective comparison of the divided insulin dose regimen with a conventional large-bolus insulin method during liver transplantation., Setting: University-based, academic, tertiary center., Participants: Adult patients whose baseline potassium levels were >/=4.0 mmol/L and received insulin therapy during liver transplantation at the authors' medical center between January 2004 and April 2007., Interventions: Insulin was administered either in divided doses (1-2 units) for each unit of red blood cells transfused or in a large-bolus in patients at high risk for hyperkalemia during liver transplantation., Measurements and Main Results: Among 717 patients who underwent liver transplantation, 50 patients received insulin in divided doses, and 101 patients received a large-bolus of insulin. Perioperative characteristics were comparable except for higher insulin doses in the large-bolus group. The divided insulin regimen was associated with significantly lower mean potassium levels within 2 hours before reperfusion of the graft compared with the conventional group (p < 0.005). The mean glucose levels in the divided group were significantly lower in both the pre- and postreperfusion periods than in the conventional group (p < 0.05 to <0.001)., Conclusions: The divided insulin dose regimen that specifically targets the risk factors for prereperfusion hyperkalemia is associated with significantly lower prereperfusion potassium and pre- and postreperfusion glucose levels and provides a useful alternative to the conventional large-bolus method in management of intraoperative hyperkalemia during liver transplantation., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Surgical site infection (SSI) is a common postoperative complication associated with increased morbidity and mortality in patients undergoing liver transplantation (LT). Although intraoperative hyperglycemia has been shown to be associated with adverse postoperative outcomes including overall infection rate in LT patients, a relationship between intraoperative hyperglycemia and SSI in LT has not been established. We sought to determine if intraoperative hyperglycemia was associated with SSI after LT., Methods: Patients undergoing LT at our medical center between January 2004 and November 2007 were included in the study. Recipient, donor, and intraoperative variables including a variety of glucose indices were retrospectively analyzed. Independent risk factors of SSI were identified using a multivariate logistic regression model., Results: Of 680 patients, 76 (11.2%) experienced postoperative SSIs. Among all intraoperative glucose indices analyzed, severe hyperglycemia (>or= 200 mg/dL) was independently associated with postoperative SSI (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.26-4.03, P=0.006). Other independent risk factors include repeat surgery (OR 6.58, 95% CI 3.41-12.69, P<0.001), intraoperative administration of vasopressor (OR 3.14, 95% CI 1.65-5.95, P<0.001), preoperative mechanical ventilation (OR 3.01, 95% CI 1.70-5.33, P<0.001), and combined liver and kidney transplantation (OR 2.95, 95% CI 3.41-12.69, P<0.001)., Conclusions: Severe, but not mild or moderate, intraoperative hyperglycemia is independently associated with postoperative SSI and should be avoided during LT surgery.

Purpose of Review: Significant changes have been witnessed recently in patients presenting for liver transplantation. The growing number of liver transplantations performed, the increasingly successful outcomes, the expansion of indications, and the implementation of the Model for End-Stage Liver Disease (MELD) system are driving forces for those changes. The purpose of this review is to examine those changes and their effect in perioperative management., Recent Findings: Patients who present for liver transplantation today have higher MELD scores and more advanced liver disease. Studies show that high MELD score patients are associated with high perioperative risks and undergo a more difficult perioperative course than patients with low MELD score. More specifically, they have more preoperative comorbidities, more baseline laboratory abnormalities, and higher requirements for intraoperative transfusion and vasopressors. Progress has been also made in management in patients with hepatocellular carcinoma, fulminant hepatic failure, and coronary artery disease prior to liver transplantation., Summary: Patients who present for liver transplantation today are more acutely ill compared with a few years ago and have more comorbidities, higher perioperative risks, and a more difficult perioperative course. Further characterization of the changes and associated perioperative risks and strategies to manage those risks are needed.

Background: Hyperkalemia poses serious hazards to patients undergoing orthotopic liver transplantation (OLT), and its predictors have not been thoroughly examined., Methods: We retrospectively studied 1124 consecutive adult patients who underwent OLT. Hyperkalemia was defined as serum K+ > or =5.5 mmol/L. A total of 47 recipient, donor, intraoperative, and laboratory variables were initially analyzed in univariate analyses. Independent predictors of hyperkalemia in three periods of OLT (prereperfusion, early postreperfusion, and late postreperfusion) were determined in multivariate logistic regression analyses., Results: Of 1124 patients, 10.2%, 19.1%, and 7.9% had hyperkalemia in the prereperfusion, early postreperfusion, and late postreperfusion periods, respectively. Higher baseline K+ and red blood cell transfusion were independent predictors of prereperfusion hyperkalemia. Higher baseline K+ (or prereperfusion K+) and donation after cardiac death donor were independent predictors of early postreperfusion hyperkalemia. Higher baseline K+, longer warm ischemia time, longer donor hospital stay, lower intraoperative urine output, and the use of venovenous bypass were independent predictors of late postreperfusion hyperkalemia., Conclusions: Several laboratory, intraoperative, and donor variables were identified as independent predictors of hyperkalemia in the different periods. Such information may be used for more targeted preemptive interventions in patients who are at risk of developing hyperkalemia during adult OLT.

In this retrospective study of 268 children undergoing liver transplantation, we investigated the incidence of intraoperative potassium (K+) disturbances and the risk factors for hypokalemia in the preperfusion and postreperfusion periods. Overall, hypokalemia was the predominant disturbance, occurring in 72.0% of pediatric patients during liver transplantation. Hypokalemia was more common during the postreperfusion period than the prereperfusion period. Hyperkalemia, though a commonly cited complication, was infrequent during pediatric liver transplantation. Using multivariate logistic regression analysis, baseline serum K+ < or =3.5 mmol/L, base excess >5 mmol/L, and creatinine < or =0.5 mg/dL were found to be predictors for hypokalemia in the prereperfusion period; and body weight < or =15 kg, K+ < or =3.5 mmol/L, fresh-frozen plasma transfusion >90 mL/kg, and absence of ascites at surgery were independent predictors for hypokalemia in the postreperfusion period. These findings support the use of K+ replacement to maintain normokalemia and avoid the potential complications related to hypokalemia in pediatric liver transplantation, especially in children with the risk factors for hypokalemia.

Background: We previously demonstrated that patients with high MELD scores required significantly higher volumes of blood transfusion and vasopressor usage during orthotopic liver transplantation (OLT) compared with patients with low MELD scores. Now we investigated whether hyponatremia or ascites were associated with increased transfusion and vasopressor requirements during OLT., Methods: Medical records of 192 OLT patients between January 1, 2004, and May 5, 2005, were retrospectively reviewed. Intraoperative transfusion of red blood cells (RBC) or fresh frozen plasma (FFP) and administration of vasopressors were compared., Results: As expected, patients with high (>30) MELD scores were associated with higher requirements for intraoperative transfusion and vasopressors than those with low ( or 30) MELD plus ascites scores (MELD+A, 4.5 points added to MELD if ascites was present) had higher requirements for transfusion and vasopressors compared with patients with low (

Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation., (Copyright 2006 AASLD)

We report a 24-year-old 36-week gestation parturient with severe aortic stenosis who developed pulmonary edema during amniocentesis and subsequently underwent a successful cesarean section under epidural anesthesia. Anesthetic management and some pertinent points are discussed.

Background: The natural history of chronic hepatitis C (CHC) remains to be defined in patients with end-stage renal disease (ESRD)., Aims: To determine the clinical presentation of CHC and the factors associated with stage III-IV fibrosis in patients with CHC and ESRD., Methods: The study included patients with CHC and ESRD (n = 91) or normal renal function (NRF, n = 159). Both groups were matched for mean age, gender, history of alcohol use, and estimated duration of hepatitis C virus (HCV) infection., Results: Presentation of CHC and ESRD was independently associated with non-Caucasian ethnicity (OR = 3.24, p= 0.0003), a history of diabetes mellitus (DM, OR = 7.911, p < 0.0001), and lower frequencies of being obese (OR = 0.457, p= 0.035), of having hepatic steatosis (OR = 0.372, p= 0.003), and stage III-IV fibrosis (OR = 0.403, p= 0.016). After adjusting for serum levels of alpha-fetoprotein (AFP) and HCV RNA, CHC, and ESRD were independently associated with lower frequencies of elevated alanine aminotransferase (ALT, OR = 0.175, p= 0.02) and aspartate aminotransferase (AST, OR = 0.169, p= 0.04), but higher frequencies of AST/ALT ratio >1 (OR = 7.173, p= 0.002) and hypoalbuminemia (OR = 9.567, p= 0.0007). Compared to patients with NRF and stage III-IV fibrosis, those with ESRD and stage III-IV fibrosis had a significantly higher frequency of a history of DM (OR = 8.014, p= 0.0031) and lower frequency of elevated AST (OR = 0.054, p= 0.004), which were independent of the frequencies of lower levels of ALT and albumin, and AST/ALT ratio >1. In patients with CHC and ESRD, the presence of stage III-IV fibrosis was significantly associated with hepatic steatosis (OR = 4.523, p= 0.012) and thrombocytopenia (OR = 4.884, p= 0.044), which were independent of the frequencies of a history of DM, splenomegaly, and a higher level of AST., Conclusions: CHC and ESRD are independently associated with a higher frequency of a history of DM, but lower frequencies of being obese, and having hepatic steatosis, stage III-IV fibrosis, and elevated transaminases. In patients with CHC and ESRD, stage III-IV fibrosis is not associated with a history of DM, but is independently associated with hepatic steatosis and thrombocytopenia.

This article reviews the current status and controversies of the 3 commonly used antifibrinolytics-epsilon-aminocaproic acid, tranexamic acid and aprotinin-during liver transplantation. There is no general consensus on how, when or which antifibrinolytics should be used in liver transplantation. Although these drugs appear to reduce blood loss and decrease transfusion requirements during liver transplantation, their use is not supported uniformly in clinical trials. Aprotinin has been studied more extensively in clinical trials and appear to offer more advantages compared to two other antifibrinolytics. Because of the diverse population of liver transplant recipients and the potential adverse effects of antifibrinolytics, especially life-threatening thromboembolism, careful patient selection and close monitoring is prudent. Further studies addressing the risks and benefits of antifibrinolytics in the setting of liver transplantation are warranted.