RESUMEN
Donation after circulatory death (DCD) represents a promising opportunity to overcome the relative shortage of donors for heart transplantation. However, the necessary period of warm ischemia is a concern. This study aims to determine the critical warm ischemia time based on in vivo biochemical changes. Sixteen DCD non-cardiac donors, without cardiovascular disease, underwent serial endomyocardial biopsies immediately before withdrawal of life-sustaining therapy (WLST), at circulatory arrest (CA) and every 2 min thereafter. Samples were processed into representative pools to assess calcium homeostasis, mitochondrial function and cellular viability. Compared to baseline, no significant deterioration was observed in any studied parameter at the time of CA (median: 9 min; IQR: 7-13 min; range: 4-19 min). Ten min after CA, phosphorylation of cAMP-dependent protein kinase-A on Thr197 and SERCA2 decreased markedly; and parallelly, mitochondrial complex II and IV activities decreased, and caspase 3/7 activity raised significantly. These results did not differ when donors with higher WLST to CA times (≥9 min) were analyzed separately. In human cardiomyocytes, the period from WLST to CA and the first 10 min after CA were not associated with a significant compromise in cellular function or viability. These findings may help to incorporate DCD into heart transplant programs.
Asunto(s)
Paro Cardíaco , Trasplante de Corazón , Obtención de Tejidos y Órganos , Muerte , Corazón , Humanos , Perfusión/métodos , Donantes de Tejidos , Isquemia TibiaRESUMEN
OBJETIVO: Determinar la seguridad de la traqueotomía percutánea por dilatación (TPD) en los pacientes receptores de un trasplante hepático. Pacientes y método: Se revisaron las historias de los pacientes ingresados para control postoperatorio de trasplante hepático (n = 291) entre octubre de 2007 y abril de 2013. En este periodo 25 pacientes trasplantados hepáticos requirieron la realización de una TPD. Se analizaron entre otros: índices de gravedad (APACHE II y SAPS II), número de días desde la intubación, razón PO2/FiO2, estudios de coagulación y complicaciones. Se compararon los resultados con la población general de pacientes críticos y las publicaciones similares en la literatura. RESULTADOS: La mediana de edad fue 58 años (RIC 47-65) y el 64% de los pacientes eran varones. La mediana desde la intubación hasta la TPD fue 11 días (RIC 6,5-15,5) y desde el trasplante hasta la TPD, 12 días. La mediana de la PO2/FiO2 fue de 212 (RIC 177-259). El recuento de plaquetas mostró valores menores en los pacientes trasplantados 89 (RIC 37-149) vs. 272 (RIC 186-381), p = 0,001. Las complicaciones incluyeron: sangrado clínicamente significativo, 8 frente al 0,3% de los pacientes críticos no trasplantados (p = 0,005), infección del estoma en el 4% y neumonía asociada a ventilación mecánica en el 16% (frente al 2,8% del resto de pacientes críticos, p = 0,007). No hubo muertes relacionadas con el procedimiento. CONCLUSIONES: La TPD es bien tolerada en los pacientes ingresados en UCI para el control postoperatorio de trasplante hepático y presenta una tasa relativamente baja de complicaciones graves y mortalidad relacionada con el procedimiento
OBJECTIVE: To determinate the safety of percutaneous dilatational tracheostomy (PDT) on hepatic allograft recipients. PATIENTS AND METHODS: We reviewed the records of patients who underwent liver transplantation between October 2007 and April 2013, followed by PDT. In this time period, 25 liver recipients underwent PDT in our intensive care unit. We recorded severity index scores such as APACHE II and SAPS II, number of days since intubation, ratios of PaO2/FiO2 (arterial oxygen pressure to fraction of inspired oxygen), coagulation study findings, complications, and procedure-related mortality rates. We compared these records with the general ICU population and literature reports. RESULTS: The median age was 58 (IC range 47-65) and 64% were men. The median time since intubation to PDT was 11 days (IC range 6.5-15.5) and from transplant to PDT 12 days. The median ratio of PaO2/FiO2 was 212 (IC range 177-259). The median platelet count was 89 (IC range 37-149), significantly lower than the general ICU population (272 (IC range 186-381) P = .001). Complications were infrequent and included clinically remarkable major bleeding 8% (vs. 0,3% in general ICU population; P = .005), peristomal infection (4%) and ventilator-associated pneumonia 16% (vs. 2,8% in general ICU population; P = .007). There were no deaths associated with the procedures. CONCLUSION: PDT was tolerated well in recipients of liver allografts and had a relatively low risk of major complications and a low procedure-related mortality rate
Asunto(s)
Humanos , Trasplante de Hígado , Traqueotomía , Periodo Posoperatorio , Complicaciones Posoperatorias/epidemiología , Seguridad del Paciente/estadística & datos numéricos , Índice de Severidad de la EnfermedadRESUMEN
OBJECTIVE: To determinate the safety of percutaneous dilatational tracheostomy (PDT) on hepatic allograft recipients. PATIENTS AND METHODS: We reviewed the records of patients who underwent liver transplantation between October 2007 and April 2013, followed by PDT. In this time period, 25 liver recipients underwent PDT in our intensive care unit. We recorded severity index scores such as APACHE II and SAPS II, number of days since intubation, ratios of PaO2/FiO2 (arterial oxygen pressure to fraction of inspired oxygen), coagulation study findings, complications, and procedure-related mortality rates. We compared these records with the general ICU population and literature reports. RESULTS: The median age was 58 (IC range 47-65) and 64% were men. The median time since intubation to PDT was 11 days (IC range 6.5-15.5) and from transplant to PDT 12 days. The median ratio of PaO2/FiO2 was 212 (IC range 177-259). The median platelet count was 89 (IC range 37-149), significantly lower than the general ICU population (272 (IC range 186-381) P=.001). Complications were infrequent and included clinically remarkable major bleeding 8% (vs. 0,3% in general ICU population; P=.005), peristomal infection (4%) and ventilator-associated pneumonia 16% (vs. 2,8% in general ICU population; P=.007). There were no deaths associated with the procedures. CONCLUSION: PDT was tolerated well in recipients of liver allografts and had a relatively low risk of major complications and a low procedure-related mortality rate.
Asunto(s)
Trasplante de Hígado , Cuidados Posoperatorios/métodos , Traqueostomía/métodos , Adulto , Anciano , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Estudios Prospectivos , Factores de TiempoRESUMEN
We report a case of acute aortic syndrome in a 64-year-old man who presented with chest pain and hypotension. His electrocardiogram and cardiac troponins were normal. Computed tomography showed hemopericardium of 2.4 cm, but no aortic intimal tear. At surgery, the portion of the aorta affected by adventitial hemorrhage was replaced with a Dacron graft. A nonpenetrating ulcerated plaque was also observed. Massive bleeding through the chest drains with hypotension required emergency reoperation in the intensive care unit. The patient was discharged home on postoperative day 11.