RESUMEN
We present a case of early skin and challenge testing in a patient following severe anaphylaxis to rocuronium. The patient presented for semi-elective laparoscopic cholecystectomy and developed anaphylaxis with severe cardiovascular collapse after induction of anaesthesia. Surgery was cancelled but was considered necessary before the recommended four to six weeks for formal allergy testing. Limited skin and challenge testing was performed to rocuronium and cisatracurium while the patient was in the intensive care unit to identify a safe neuromuscular blocking drug for subsequent early surgery. The subsequent surgery, 48 hours after the initial reaction, was uneventful. The case highlights the difficulties when anaesthetising patients with recent anaphylaxis who have not yet had formal allergy testing and presents a potential management strategy involving early skin testing.
Asunto(s)
Anafilaxia/inducido químicamente , Androstanoles/efectos adversos , Fármacos Neuromusculares no Despolarizantes/efectos adversos , Adolescente , Anafilaxia/diagnóstico , Anafilaxia/inmunología , Androstanoles/inmunología , Atracurio/efectos adversos , Atracurio/análogos & derivados , Atracurio/inmunología , Colecistectomía Laparoscópica/métodos , Femenino , Humanos , Fármacos Neuromusculares no Despolarizantes/inmunología , Rocuronio , Pruebas CutáneasRESUMEN
INTRODUCTION: Although the early effects of brain death on the organ donor are well described, there is a paucity of information on the impact of donor brain death on the transplanted recipient's heart in both the short and long term. The few studies published report conflicting results. The aim of this article was to undertake a retrospective exploratory study examining the impact of brain death in the donor on recipient outcomes with respect to the cardiac allograft, specifically looking at primary graft failure (PGF), postoperative rejection, and survival. METHODS: A total of 215 consecutive orthotopic heart transplants performed between June 2001 and March 2011 were included in this retrospective exploratory analysis. RESULTS: Brain death time had no association with rejection-free period or mortality in this study cohort. Use of intra-aortic balloon pump support after donor allograft implantation (assessed as an indicator of PGF) was significantly associated with brain death time (odds ratio 0.998 [95% confidence interval 0.997-0.999]; P = .023) on univariate analysis with longer brain death time associated with a lower incidence of PGF. A strong correlation between brain death time and hypoxia inducible factor 1α enzyme activity in donor atrial tissue was found (r = .56; P = .002). CONCLUSION: This study indicates that there is an association between brain death time and PGF. A longer interval from brain death may give the donor heart more time to recover from the catecholamine storm. This may have implications for donation after circulatory death donor hearts, which have not been subjected to this catecholamine storm and may potentially be less likely to suffer PGF as a result.
Asunto(s)
Muerte Encefálica , Supervivencia de Injerto , Insuficiencia Cardíaca/cirugía , Trasplante de Corazón/métodos , Donantes de Tejidos , Adulto , Femenino , Rechazo de Injerto , Insuficiencia Cardíaca/mortalidad , Humanos , Subunidad alfa del Factor 1 Inducible por Hipoxia/metabolismo , Inmunosupresores/uso terapéutico , Masculino , Persona de Mediana Edad , Miocardio/patología , Oportunidad Relativa , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: There is little data available on the specific effects of warm ischemia time (WIT) as opposed to cold ischemia or storage time. With current research endeavors focusing on warm continuous perfusion, storage of donor hearts, and utilization of hearts from non-heart-beating donors, the impact of WIT on outcomes is increasingly relevant. The aim of this study was to analyze our results in cardiac transplantation with specific focus on the impact of WIT. METHODS: A retrospective review of 206 patients who underwent orthotopic heart transplantation at our institution between June 2001 and November 2010 was performed. Donor, recipient, and operative factors were analyzed. The main outcome variables were all cause mortality, survival, and primary graft failure. RESULTS: WIT of >80 minutes was associated with reduced survival compared with a shorter WIT of <60 minutes. Multivariate analysis showed increasing donor age to be the most significant variable associated with increased risk of mortality (hazard ratio 1.04; P = .004) per year of increasing donor age. CONCLUSIONS: This study has demonstrated a reduced survival in heart transplant recipients with increased WIT. This finding may be of particular relevance to potential future heart transplantation using organs procured from non-heart-beating donors.