Best practice & research. Clinical anaesthesiology
-
Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewEconomic considerations in abdominal transplantation.
Care for end-stage organ failure through transplant is one of the landmark accomplishments of the modern medicine. At the same time, organ transplant is a resource-intensive service that has been under increasing scrutiny in this era of cost containment. A detailed understanding of the economic implications of organ quality, recipient characteristics, and allocation policy is vital for the transplant professionals. ⋯ Liver transplantation economics are also more challenging because of organ allocation based on the severity of illness. Furthermore, the broader use of marginal organs has been demonstrated to increase costs. Novel strategies are vital to reduce the financial burden faced by the centers that perform transplantations on elevated risk patients and utilize lower quality organs.
-
Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewCritical care management in patients with acute liver failure.
Acute liver failure (ALF) is defined as severe hepatic dysfunction (marked transaminases elevation, detoxification disorder (jaundice and coagulopathy with international normal ratio (INR) > 1.5), the presence of hepatic encephalopathy, and exclusion of underlying chronic liver disease, and a secondary cause like sepsis or cardiogenic shock. Reasons for ALF include paracetamol and warfarin toxicity, autoimmune and viral (mainly hepatitis B and E) hepatitis, and herbal and dietary supplements. Even in terms of meticulous and careful review of the patient, around 20-30% of the reasons remains unknown. ⋯ However, because of improved ICU treatment, the mortality, even in the advanced stage of ALF decreased. However, in 5-10% of the cases an emergency transplantation is required. This justifies the treatment of this patient cohort in institutions that can provide this kind of treatment.
-
Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewAcute kidney injury: A critical care perspective for orthotopic liver transplantation.
Acute kidney injury (AKI) is associated with high perioperative mortality in patients undergoing liver transplantation (LT). In the era of Model of End-stage Liver Disease score-based allocation, more patients with impaired renal function are receiving LT. The majority of preoperative AKI is secondary to azotemia, including hepatorenal syndrome - a progressive form of renal impairment unique to liver failure. ⋯ Given that, the healthcare providers must develop an expertise in liver failure-related renal complications, specifically their management and perioperative implications. Notably, AKI may complicate intraoperative course, exacerbating hemodynamic instability, metabolic acidosis, and electrolyte and coagulation abnormalities. Adjunctive intraoperative continuous renal replacement therapy has been employed; however, prospective studies remain necessary to validate potential benefits.
-
Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewPerioperative considerations for kidney and pancreas-kidney transplantation.
Kidney transplantation is the treatment of choice in patients with end-stage renal disease, as it improves survival and quality of life. Living donor kidney transplant prior to pancreas transplantation, or simultaneous pancreas and kidney transplantation are discussed. Patients usually present comorbidities and extensive preoperative workups are recommended, especially cardiac assessment, though type and frequency of surveillance is not established. ⋯ Notably, transplantation in the obese population has increased in recent decades. Strict preoperative evaluation and pulmonary considerations must be kept in mind. Finally, robotic kidney transplant is a recent approach that presents anesthetic challenges, mainly related to steep Trendelenburg position and fluid restriction.
-
Best Pract Res Clin Anaesthesiol · Mar 2020
ReviewCoagulation, hemostasis, and transfusion during liver transplantation.
Liver disease is associated with complex disturbances of hemostasis that affect both the pro- and anticoagulant systems. This results in a "rebalanced" coagulation system that may result in bleeding diathesis or increased clot formation. ⋯ Specific recommendations for transfusion of platelets, fresh frozen plasma, cryoprecipitate, and fibrinogen as well as factor concentrates are discussed. In general transfusion should not only be guided by laboratory values but it also includes a clinical assessment of clot formation.