Indices of Nutrition Status of Kidney and Pancreas Transplant Candidates

Nutritional assessment is used to implement early nutritional interventions and reduce complications associated with malnutrition, which plays a crucial role in improving postoperative outcomes for patients undergoing pancreas and/or kidney transplantation.

OBJECTIVE

The aim of this study was to analyze the nutritional status (NS) in patients eligible for kidney transplantation (KTx) and simultaneous kidney-pancreas transplantation (SPKTx).

METHODS

We analyzed the database of hospitalized patients from 2020 to 2023 to identify preoperative parameters of NS in patients eligible for KTx and SPKTx. A total of 59 patients participated in the study, all of whom were candidates for KTx-23 or SPKTx-36. The study population consisted of 35 women (W) and 24 men (M), with an overall mean age of 44.8 ± 10.2 years (43.5 ± 10.2 years for W and 46.2 ± 10.9 years for M). Both groups included patients on hemodialysis (n = 34) and peritoneal dialysis (n = 12), and patients in the predialysis period (pre-emptive, n = 13). The examined parameters included Onodera's prognostic nutritional index (PNIO), the nutritional risk index (NRI), proper body mass calculated using the Lorenz formula, and the neutrophil-to-lymphocyte ratio (NLR). All patients were assessed according to the NRS 2002 scale.

RESULTS

Analysis of the obtained results revealed that the NLR was only one differentiating parameter between Ktx and SPKtx group. Multivariate analysis adjusted for patients' age and gender, comparing quantitative NS indicators was performed. Albumin serum concentration was not dependent on patients' group (KTx/SPKTx) neither age nor gender P = .382. BMI was dependent on patients' age and gender, but not a group (KTx/SPKTx) P = .008. PNIO, NRI, and NRL were not dependent on patients' group (KTx/SPKTx) neither age nor gender.

CONCLUSIONS

Additional effort should be devoted to the development of a proper nutrition plan for SPKTx a especially in peritoneal dialysis patients. Toward patients on the waiting list, the regular assessment of nutritional status should be performed which is not a rule in dialysis centers. SPKTx candidates in the perioperative period should receive proper nutrition taking into account their caloric and protein needs.

Postoperative Supplemental Oxygen in Liver Transplantation (PSOLT) does not reduce the rate of infections: results of a randomized controlled trial

BACKGROUND

Despite inconsistent evidence, international guidelines underline the importance of perioperative hyperoxygenation in prevention of postoperative infections. Further, data on safety and efficacy of this method in liver transplant setting are lacking. The aim was to evaluate efficacy and safety of postoperative hyperoxygenation in prophylaxis of infections after liver transplantation.

METHODS

In this randomized controlled trial, patients undergoing liver transplantation were randomly assigned to either 28% or 80% fraction of inspired oxygen (FiO₂) for 6 postoperative hours. Infections occurring during 30-day post-transplant period were the primary outcome measure. Secondary outcome measures included 90-day mortality, 90-day severe morbidity, 30-day pulmonary complications, durations of hospital and intensive care unit stay, and 5-day postoperative bilirubin concentration, alanine and aspartate transaminase activity, and international normalized ratio (INR) (clinicatrials.gov NCT02857855).

RESULTS

A total of 193 patients were included and randomized to 28% (n = 99) and 80% (n = 94) FiO₂. With similar patient, operative, and donor characteristics in both groups, infections occurred in 34.0% (32/94) of patients assigned to 80% FiO₂ as compared to 23.2% (23/99) of patients assigned to 28% FiO₂ (p = 0.112). Patients randomized to 80% FiO₂ more frequently developed severe complications (p = 0.035), stayed longer in the intensive care unit (p = 0.033), and had higher bilirubin concentration over first 5 post-transplant days (p = 0.043). No significant differences were found regarding mortality, duration of hospital stay, pulmonary complications, and 5-day aspartate and alanine transaminase activity and INR.

CONCLUSIONS

Postoperative hyperoxygenation should not be used for prophylaxis of infections after liver transplantation due to the lack of efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02857855. Registered 7 July 2016.

Clinical Implication of Plasma CD163 in Patients With Acute-on-Chronic Liver Failure

BACKGROUND

It was postulated that CD163 plasma level should be incorporated into existing predictive systems to improve prognostic performance in patients with acute-on-chronic liver failure (ACLF).

PATIENTS AND METHODS

Plasma CD163 was assessed in 24 consecutive patients with ACLF (17 male, 7 female; mean age 54.9 years; 50% with alcohol-related liver disease) and compered with the existing scoring tools to predict the availability of transplantation or survival without liver transplant (LT).

RESULTS

There were no differences in plasma CD163 levels between graft recipients and deceased patients on the waiting list or transplant survivors vs nonsurvivors. CD163 did not correlate with CLIF-ACLF, CLIF Consortium organ failure score (CLIF-OF), and ACLF grades (all P < .05). However, sequential organ failure assessment (SOFA), CLIF Consortium acute-on-chronic liver failure score (CLIF-C) ACLF, and CLIF-C OF scores correlated significantly with mortality (P < .01) in contrast to Child-Pugh scale and Model for End-Stage Liver Disease score (all P > .05). Transplanted survivors and deceased individuals differed robustly with respect to the SOFA and CLIF-SOFA scores and the CLIF-C OF, CLIF-C Grade, and CLIF-C ACLF scales (all P < .05). CLIF-C performed well in ACLF prognostication with an area under receiver operating characteristic curve (AUROC) 0.893 (95% CI, 0.766-1), surpassing in that respect CD163 with AUROC of 0.664 (95% CI, 0417-0.911).

CONCLUSIONS

Our preliminary results showed that the plasma CD163 level in patients with ACLF played only a minor role in predicting LT futility/benefit, with no impact on the narrow transplant window. Moreover, to optimize LT outcomes, newly developed CLIF-C scales showed superior predictive value.

Kidney Function After Liver Transplantation in a Single Center

Background

Renal dysfunction in the peri-transplant period appears to complicate both short- and long-term outcome of liver transplantation (LT). The aim of this study was to analyze the impact of selected clinical features in the peri-liver transplant period, as well calcineurin inhibitor, particularly tacrolimus given after LT, on kidney function in a single liver transplant center’s experience.

Material/Methods

A total 125 consecutive liver-grafted individuals (82 M, 43 F), mean age 50±13 y (with alcohol-related liver disease in 48 (38%) patients) were included into the study. Their clinical data were collected in the database until 46 months of follow-up, and the Python packages Pandas (version 0.22.0) and scikit-learn (version 0.21.3) were used for data analysis.

Results

More advanced liver disease as judged by Child-Pugh class and MELD score differed significantly patients with preserved (serum creatinine SCr <1.5 mg/dL) and impaired (SCr ≥1.5 mg/dL) kidney function before LT. Older age and higher SCr pre-LT were associated with higher levels of SCr after LT in 2 time-points. SCr before LT was correlated with delta SCr for the highest and last recorded value (P<0.0001). Higher amounts of transfused colloids during surgery were associated with increased delta SCr for the highest value (P=0.019) after grafting in logistic regression analysis. There were no associations between SCr after LT and duration of anhepatic phase, urine output ≤100 mL/h, or post-reperfusion syndrome during transplantation (all P>0.05). There were no associations between SCr after LT and tacrolimus trough levels in analyses of correlations and linear regression analyses (all P>0.05).

Conclusions

We found that pretransplant serum creatinine was the only factor affecting kidney function after LT in our liver transplant center. The restricted fluid policy was safe and effective in terms of long-term renal function. The role of kidney-saving immunosuppressive protocols in preserving renal function long-term after LT was also confirmed.

Acute-On-Chronic Liver Failure: The Role of Prognostic Scores in a Single-Center Experience

Background

Acute-on-chronic liver failure (ACLF) is associated with multi-organ failure and high short-term mortality. We evaluated the role of currently available prognostic scores for prediction of 90-day mortality in ACLF patients.

Material/Methods

Fifty-five (M/F=40/15, mean age 60.0±11.1years) consecutive cirrhotic patients with severe liver insufficiency (mean MELD 28.4±9.0, Child-Pugh score – C-12) were enrolled into the study. MELD variants and SOFA, CLIF-SOFA, and CLIF-C scores were calculated, mortality predicting factors were identified, and clinical comparisons between ACLF and AD patients were performed.

Results

In total, 30 (55%) patients were transplanted (22 ACLF and 8 AD), and 20 (30%) died (19 ACLF and 1 AD). Five (9%) patients survived without liver transplantation (LT) (3 ACLF and 2 AD), and 3 transplant recipients died within 1 month. SOFA, CLIF-SOFA, CLIF-C OF, and INR were significantly associated with the incidence of 90-day mortality in competing risk regression analysis (all p<0.001). The model based on SOFA had the lowest BIC, with the optimal cut-off for 90-day mortality prediction ≥12, with the area under the receiver operating characteristic (AUROC) of 0.901 (95% CI 0.779–1.000; p<0.001), and corresponding incidence of transplantation rates of 85.5% and 11.8%, respectively (p<0.001). Of note, the important role of 24-h urine output is emphasized.

Conclusions

In this series of ACLF patients, SOFA score outperformed the CLIF-C scores in predicting 90-day mortality. Multi-organ failure scores performed better in predicting patient mortality than conventional liver function assessment. LT is possible and remains effective in selected ACLF patients.

A Comparison of Intrathecal and Intravenous Morphine for Analgesia After Hepatectomy: A Randomized Controlled Trial

BACKGROUND

Effective analgesia is essential for patient recovery after liver resection. This study aimed to evaluate the effects of the addition of preoperative intrathecal morphine to multimodal intravenous analgesia in patients undergoing liver resection.

METHODS

In this single-blind randomized controlled trial, patients undergoing liver resection were randomly assigned to the patient-controlled analgesia with (ITM-IV) or without (IV) preoperative intrathecal morphine groups. All patients received acetaminophen and dexketoprofen. The primary outcome was pain severity at rest over three postoperative days, assessed using the numerical rating scale (NRS).

RESULTS

The study included 36 patients (18 in each group). The mean maximum daily NRS scores over the first three postoperative days in the ITM-IV and IV groups were 1.3, 1.1, and 0.3 and 1.6, 1.1, and 0.7, respectively (p = 0.580). No differences were observed in pain severity while coughing, with corresponding scores of 2.8, 2.1, and 1.1, respectively, in the ITM-IV group and 2.3, 2.2, and 1.5, respectively, in the IV group (p = 0.963). Proportions of patients reporting clinically significant pain at rest and while coughing were 11.1% and 44.4%, respectively, in the ITM-IV group, and 16.7% and 44.4%, respectively, in the IV group (both p > 0.999). Cumulative morphine doses in the ITM-IV and IV groups were 26 mg and 17 mg, respectively (p = 0.257). Both groups also showed similar time to mobilization (p = 0.791) and solid food intake (p = 0.743), sedation grade (p = 0.584), and morbidity (p = 0.402).

CONCLUSIONS

Preoperative intrathecal morphine administration provides no benefits to multimodal analgesia in patients undergoing liver resection.

TRIAL REGISTRATION NUMBER

Clinicaltrial.gov Identifier: NCT03620916.

Comparative effectiveness of torasemide versus furosemide in symptomatic therapy in heart failure patients: Preliminary results from the randomized TORNADO trial

BACKGROUND

Recent reports suggest that torasemide might be more beneficial than furosemide in patients with symptomatic heart failure (HF). The aim was to compare the effects of torasemide and furosemide on clinical outcomes in HF patients.

METHODS

This study pilot consisted of data from the ongoing multicenter, randomized, unblinded endpoint phase IV TORNADO (NCT01942109) study. HF patients in New York Heart Association (NYHA) II-IV class with a stable dose of furosemide were randomized to treatment with equipotential dose of torasemide (4:1) or continuation of unchanged dose of furosemide. On enrollment and control visit (3 months after enrollment) clinical examination, 6-minute walk test (6MWT) and assessment of fluid retention by ZOE Fluid Status Monitor were performed. The primary endpoint was a composite of improvement of NYHA class, improvement of at least 50 m during 6MWT and decrease in fluid retention of at least 0.5 W after 3-months follow-up.

RESULTS

The study group included 40 patients (median age 66 years; 77.5% male). During follow-up 7 patients were hospitalized for HF worsening (3 in torasemide and 4 in furosemide-treated patients). The primary endpoint reached 15 (94%) and 14 (58%) patients on torasemide and furosemide, respectively (p = 0.03).

CONCLUSIONS

In HF patients treated with torasemide fluid overload and symptoms improved more than in the furosemide group. This positive effect occurred already within 3-month observation.

Fulminant liver failure following a marathon: Five case reports and review of literature

BACKGROUND

The growing popularity of marathon and half-marathon runs has led to an increased number of patients presenting with exertion-induced heat stroke. Mild hepatic involvement is often observed in these patients; however, fulminant liver failure may occur in approximately 5% of all cases. Liver transplantation is a potentially curative approach for exertion-induced liver failure, although there is a lack of consensus regarding the criteria and optimal timing of this intervention.

CASE SUMMARY

This paper describes 5 patients (4 men and 1 woman) who were referred to the department where this study was performed with the diagnosis of exertion-induced acute liver failure. Three patients underwent liver transplantation, 1 recovered spontaneously, and 1 patient died on day 11 following the exertion.

CONCLUSION

Exertion-induced heat stroke may present as fulminant liver failure. These patients may recover with conservative treatment, may require liver transplantation, or may die. No definitive criteria are available to determine patient suitability for a conservative vs surgical approach.

Renaissance of Modified Charlson Comorbidity Index in Prediction of Short- and Long-Term Survival After Liver Transplantation?

Background

Orthotopic liver transplantation (OLT) is the standard of care for end-stage liver disease. The Charlson Comorbidity Index (CCI) was originally created to assess the survival rate of patients with chronic diseases, although it was modified and adopted in OLT recipients as CCI-OLT.

Material/Methods

In total of 248 consecutive liver transplant recipients with viral cirrhosis in 98 (39.5%) patients were included. CCI-OLT was calculated assigning a weight of 3 to chronic obstructive pulmonary disease; weight of 2 to coronary artery disease, connective tissue disease, and renal insufficiency; and a weight of 1 to diabetes mellitus.

Results

CCI-OLT was significantly correlated with recipient age (p<0.001; R=0.333) and was a significant risk factor for early post-transplant mortality (p=0.004). The presence of diabetes mellitus significantly increased the odds of early mortality (p=0.010). The optimal cut-off for CCI-OLT in prediction of mortality during the first 90 days after transplantation was ≥1, with an AUROC of 0.780 (95% CI: 0.670–0.891; p<0.001). Increasing CCI-OLT was a significant risk factor for worse 5-year post-transplant survival (p=0.001), along with coronary artery disease (p=0.008) and diabetes mellitus (p=0.021). The optimal cut-off for prediction of 5-year mortality for CCI-OLT was ≥1, with the AUROC of 0.638 (95% CI: 0.544–0.733; p=0.004).

Conclusions

CCI-OLT is a useful tool for measuring the effect of pretransplant comorbidities and to stratify the effect of risk on both short- and long-term outcomes after OLT. Recipient age and diabetes strongly affected short-term survival after OLT, and metabolic and vascular complications were the leading causes of death at 5 years after OLT.

Safety of propofol-based anesthesia for colonoscopy in older patients

We retrospectively analyzed whether sedation for colonoscopy in older patients is as safe as in younger patients. This case-control study evaluated 149 consecutive older patients aged ≥65 years and 149 younger patients aged <65 years hospitalized in a tertiary hospital gastroenterology reference center for colonoscopy with propofol sedation. Data on American Society of Anesthesiologists (ASA) class, dose of propofol, dose of intravenous fluids, blood pressure, heart rate, saturation, both before and during anesthesia were collected. Additionally, physician experience, duration of anesthesia, and recovery time were analyzed. The median age was 74,2 years in the older group and 49,4 years in the younger group. Patients were mainly ASA II in both groups. The dose of propofol administered was higher in the younger vs the older group (2,9 vs 2,01 mg/kg, p <0,0001). There were no bradyarrhythmias, no hypotension and no decrease in saturation in either group. There were no differences in blood pressure, heart rate, and saturation in older patients, regardless of whether anesthesia was performed by a resident or a specialist. In this setting, colonoscopy under propofol-based sedation in patients ≥65 years was as safe as in younger patients and there was no difference in safety when the anesthetic was administered by a resident or a specialist in anesthesiology. These data suggest that older patients do not need a longer hospital stay because of sedation.

Successful Hepatoatrial Anastomosis During a Consecutive Liver Retransplant in the Same Patient Shows Good Long-Term Results: Case Report and 2-Year Follow-Up

Liver retransplant is the last and only treatment for patients with irreversible graft failure. It is recognized as a high-risk procedure; thus surgical difficulties are multiplied with every successive liver transplant. Liver retransplant is a demanding technical procedure for the surgeon, with no guarantee of postoperative and long-term survival. Here, we report a 29-year-old male patient who underwent a liver transplant in April 2009 due to primary sclerosing cholangitis with overlapping autoimmune hepatitis. The patient underwent liver retransplant in May 2012 due to graft failure. A second liver retransplant was performed in April 2013 using the classical technique. An inflammatory process involving the inferior vena cava and diaphragm forced the surgeon to open the pericardium from the diaphragm and clamp the cuff of the right atrium to perform a hepatoatrial anastomosis of the inferior vena cava. The next steps were performed as for a typical liver transplant. Postoperative stay was free of complications and was not prolonged. Immunosuppression regimen was kept standard. During our follow-up of more than 32 months, the patient continued to show good results. A consecutive hepatectomy in the same recipient is associated with an increased risk of intraoperative complications. When excessive adhesions limit a safe and functioning cavocaval anastomosis, a hepatectomy with the excision of the intrahepatic inferior vena cava and end-to-end anastomosis through a pericardial window for the extension of the recipient's' vena cava cuff are feasible options. We found that a hepatoatrial anastomosis does not impair good overall outcomes and long-term results.

Evolution Of The Results Of 1500 Liver Transplantations Performed In The Department Of General, Transplant And Liver Surgery Medical University Of Warsaw

Liver transplantation is a well-established treatment of patients with end-stage liver disease and selected liver tumors. Remarkable progress has been made over the last years concerning nearly all of its aspects. The aim of this study was to evaluate the evolution of long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery (Medical University of Warsaw).

MATERIAL AND METHODS

Data of 1500 liver transplantations performed between 1989 and 2014 were retrospectively analyzed. Transplantations were divided into 3 groups: group 1 including first 500 operations, group 2 including subsequent 500, and group 3 comprising the most recent 500. Five year overall and graft survival were set as outcome measures.

RESULTS

Increased number of transplantations performed at the site was associated with increased age of the recipients (p<0.001) and donors (p<0.001), increased rate of male recipients (p<0.001), and increased rate of piggyback operations (p<0.001), and decreased MELD (p<0.001), as well as decreased blood (p=0.006) and plasma (p<0.001) transfusions. Overall survival was 71.6% at 5 years in group 1, 74.5% at 5 years in group 2, and 85% at 2.9 years in group 3 (p=0.008). Improvement of overall survival was particularly observed for primary transplantations (p=0.004). Increased graft survival rates did not reach the level of significance (p=0.136).

CONCLUSIONS

Long-term outcomes after liver transplantations performed in the Department of General, Transplant and Liver Surgery are comparable to those achieved in the largest transplant centers worldwide and are continuously improving despite increasing recipient age and wider utilization of organs procured from older donors.

Perioperative bleeding in patients undergoing liver transplantation

Liver transplantation (LT) remains one of the most challenging surgical procedures. For many years uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During the past fifty years or so, significant progress in surgical techniques and perioperative management has led to a marked change in transfusion practice over time, where up to 79.6% of LTs in experienced transplant centers are performed without any blood product transfusion. Despite this, perioperative bleeding and transfusion requirements remain potent predictors of patient's mortality, as well as postoperative complications and graft survival. The major impact of blood product transfusion on LT recipient outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. Although multiple predictors of transfusion requirements during LT have been identified, no predictive model validated across centers has been constructed. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in the management of haemostasis in LT recipients.

Prognostic scoring systems for mortality in intensive care units--the APACHE model

The APACHE (Acute Physiology and Chronic Health Evaluation) scoring system is time consuming. The mean time for introducing a patient's data to APACHE IV is 37.3 min. Nevertheless, statisticians have known for years that the higher the number of variables the mathematical model describes, the more accurate the model. Because of the necessity of gathering data over a 24-hour period and of determining one cause for ICU admission, the system is troublesome and prone to mistakes. The evolution of the APACHE scoring system is an example of unfulfilled hopes for accurately estimating the risk of death for patients admitted to the ICU; satisfactory prognostic effects resulting from the use of APACHE II and III have been recently studied in patients undergoing liver transplantations. Because no increase in the predictive properties of successive versions has been observed, the search for other solutions continues. The APACHE IV scoring system is helpful; however, its use without prepared spreadsheets is almost impractical. Therefore, although many years have passed since its original publication, APACHE II or its extension APACHE III is currently used in clinical practice.

Results of liver transplantation in the Department of General, Transplant and Liver Surgery at the Medical University of Warsaw in patients with chronic hepatitis B and C viruses infection

INTRODUCTION

Cirrhosis related to hepatitis C virus (HCV) and hepatitis B virus (HBV) infection is the most frequent indication for liver transplantation worldwide. Progress in prophylaxis of posttransplant HBV recurrence has led to major improvements in long-term outcomes of patients after liver transplantation. Conversely, impaired posttransplant survival of patients with HCV infection was reported in several studies, mainly due to recurrence of viral infection. The purpose of this study was to compare long-term results of liver transplantation between patients with HBV monoinfection, HCV monoinfection and HBV/HCV coinfection.

MATERIAL AND METHODS

A total of 1090 liver transplantations were performed in the Department of General, Transplant and Liver Surgery in cooperation with the Department of Immunology, Internal Medicine, and Transplantology at the Transplantation Institute Medical University of Warsaw between December 1994 and May 2012. After exclusion of patients with cirrhosis of non-viral etiology, patients with malignant tumors, and patients with acute liver failure, the final study cohort comprised 209 patients with HBV (HBV+/HCV- subgroup; n = 56) or HCV (HBV-/HCV+ subgroup; n = 119) monoinfection or HBV/HCV coinfection (HBV+/HCV+; n = 34). These subgroups of patients were compared in terms of long-term results of transplantations, defined by 5-year patient and 5-year graft survival estimates.

RESULTS

Overall and graft survival rates after 5-years for the whole study cohort were 74.5% and 72.6%, respectively. Five-year overall survival was 70.4% for patients within the HBV+/HCV- subgroup, 77.8% for patients within the HBV-/HCV+ subgroup, and 68.5% for patients within the HBV+/HCV+ subgroup. The corresponding rates of graft survival were 67.0%, 76.3%, and 68.5% for patients within the HBV+/HCV-, HBV-/ HCV+, and HBV+/HCV+ subgroups, respectively. Observed differences were non-significant, both in terms of overall (p = 0.472) and graft (p = 0.461) survival rates.

CONCLUSIONS

Both overall and graft survival rates after liver transplantations performed in the Department of General, Transplant and Liver Surgery in cooperation with the Department of Immunology, Internal Medicine, and Transplantology at the Transplantation Institute Medical University of Warsaw in patients with HBV and HCV infection are comparable to those reported by other European and American centers. In contrast to other studies, obtained results do not confirm the negative impact of HCV infection on long-term outcomes of patients.

Mortality scoring in ITU

Chronic shortage of ITU beds makes decisions on admission difficult and responsible. The use of computer-based mortality scoring should help in decision-making and for this purpose, a number of different scoring systems have been created; in principle, they should be easy to use, adaptable to all populations of patients and suitable for predicting the risk of mortality during both ITU and hospital stay. Most of existing scales and scoring systems were included in this review. They are frequently used in ITUs and become a necessary tool to describe ITU populations and to explain differences in mortality. As there are several pitfalls related to the interpretation of the numbers supplied by the systems, they should be used with the knowledge on the severity scoring science. Moreover, the cost and significant workload limit the use of scoring systems; in many cases an extra person has to be employed for collection and analysis of data only.

[The skin incisions (blow holes) for treatment of massive subcutaneous emphysema]

BACKGROUND

Subcutaneous emphysema (SE) is rarely life-threatening, although it may create significant discomfort to patients. It may impede eye opening, movement of the limbs and sometimes causes stridor and respiratory distress. We describe two cases of SE, in which small incisions in the skin helped to relieve symptoms.

CASE REPORTS

Case 1. A 64-year-old male was admitted to ITU, having been intubated after blunt chest trauma during a traffic accident. Initial presentation included respiratory failure, massive SE of the face, neck and chest, and fractured ribs with bilateral pneumothorax and bilateral lung contusion. Ventilation with BiPAP with 15 cm H2O PEEP was commenced and a right chest drain was inserted. This resulted in rapid improvement of gas exchange, but SE became progressively larger. On the second day, several 2 cm skin incisions were made bilaterally in the subclavicular regions; immediately a loud hiss of escaping air was heard and the patient's condition improved rapidly. He was extubated after seven days and made a full recovery. Case 2. A 42-yr-old male was admitted to ITU three days after a street fight because of rapidly progressing SE, extending to the head, neck, chest, abdomen and legs. He was suffering from pneumomediastinum, pneumopericardium, and broken ribs, hyoid bone and Th10 spinous process. An emergency tracheostomy was performed and blow holes were made in both subclavicular regions. This resulted in rapid improvement and he was discharged home after two weeks in hospital.

DISCUSSION AND CONCLUSION

Several methods of treatment for severe SE have been described, including pleural drainage, subcutaneous insertion of pig-tail drains, iv cannulas or large bore drains. The method described, albeit not always successful, is simple and can be applied in every setting.

[Cardiac arrest in chronic metabolic alkalosis due to sodium bicarbonate abuse]

BACKGROUND

Moderate metabolic alkalosis has not been considered as a life-threatening situation by many authors, but when it persists and pH increases above 7.65, the situation may become critical.

CASE REPORT

We present a case of a 61-yr-old alcoholic male patient, who had been consuming approximately 200 g of sodium bicarbonate daily for twenty years, due to persisitent heartburn and abdominal pains. The patient was admitted to the ITU after home cardiac arrest and resuscitation. On admission he was unconscious and in respiratory distress, with a GCS of 5. Blood gases revealed that his pH was 7.64, HCO3 44 mmol L(-1), K+ 2.4 mmol L(-1)l, Cl- 44 mmol L(-1), and lactate concentration over 15 mmol L(-1). He was treated with controlled hypercapnia, up to a PaCO2 of 63 mm Hg, sedation, and administration of a large amount of chloride (864 mmol during the first day). The patient regained consciousness after 48 h, was extubated and transferred to the internal medicine department where he died 3 days later.

DISCUSSION

Chronic alkali abuse can lead to various metabolic disturbances, neurologic disturbances and cardiovascular compromise. In the described case, the exact cause of cardiac arrest remained unknown, but may have been caused by alkalosis combined with hypoxia, hypokalemia and poor general condition. The extreme metabolic alkalosis (pH 7.8) could also have been enhanced by the administration of i.v. sodium bicarbonate during resuscitation. The treatment of choice in such cases should consist of vigorous chloride containing fluid resuscitation, ammonium chloride and hemodialysis.