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Massive haemorrhage in liver transplantation:Consequences,prediction and management

World Journal of Transplantation 2016年第2期6卷 291-305页

作者： Stuart Cleland Carlos Corredor Jia Jia Ye Coimbatore Srinivas Stuart A Mc Cluskey Department of Anesthesia and Pain Management Toronto General HospitalUniversity Health Network Department of anesthesia University of Toronto

From its inception the success of liver transplantation has been associated with massive blood loss. Massive transfusion is classically defined as > 10 units of red blood cells within 24 h, but describing transfusion rates over a shorter period of time may reduce the potential for survival bias. Both massive haemorrhage and transfusion are associated with increased risk of mortality and morbidity(need for dialysis/surgical site infection) following liver transplantation although causality is difficult to prove due to the observational design of most trials. The blood loss associated with liver transplantation is multifactorial. Portal hypertension secondary to cirrhosis results in extensive collateral circulation, which can bleed during hepatectomy particular if portal pressures are increased. Avoiding volume loading and maintenance of a low central venous pressure together with the use of vasopressors have been shown to reduce blood loss and transfusion during liver transplantation, but may increase the risk of renal impairment post-operatively. Coagulation defects may be present pre-transplant, but haemostasis is often re-balanced due to a deficit in both proand anti-coagulation factors. Further derangement of haemostasis may develop in the anhepatic and neohepatic phases due to absent hepatic metabolic function, hyperfibrinolysis and platelet sequestration in the donor liver. Point-of-care tests of coagulation such as the viscoelastic tests rotation thromboelastometry/thromboelastometry allow and more accurate and rapid assessment of these derangements in coagulation and guide the use of factor replacement and antifibrinolytics. Transfusion protocols guided by these tests have been shown to reduce transfusion rates compared with conventional coagulation tests, but have not shownimprovements in mortality or morbidity. Pre-operative factors associated with massive transfusion include previous surgery, re-do transplantation, the aetiology and severity of liver disease. Intra-operatively the use of piggy-back tech

关键词： Liver transplantation Massive transfusion Coagulopathy

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A Multi-centered Cross-sectional Study of Disease Burden of pain of Inpatients in Southwest China

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Chinese Medical Journal 2016年第8期129卷 936-941页

作者： Li-Hua Peng Ju-Yin Jing Pei-Pei Qin Min Su Department of anesthesia and pain Medicine The First Affiliated Hospital of Chongqing Medical University Chongqing 400016 China

Background：pain is a common burden of disease globally;yet,it is not systematically investigated in China,especially in hospitalized patients.This study was aimed at clarifying the epidemiological characteristics of pain and related factors in hospitalized patients in Southwest China.Methods：A cross-sectional study was conducted to investigate the prevalence,severity,and influencing factors of pain and modes of postoperative analgesia in hospitalized patients from 17 hospitals in Southwest China.A prevalidated questionnaire was employed to calibrate all of these items within 3 days from March 18,2015 to March 20,2015.Results：A total of 2293 patients were surveyed,the incidence of pain was 57.4% in all hospitalized patients at rest,of which 62.1% were with acute pain and 37.9% had persistent to chronic pain.Among surgical patients,90.8% of them complained of acute postoperative pain at rest and 97.1% in motion.The incidence of acute postoperative moderate-to-severe pain was 28.8% at rest and 45.1% in motion.Surgical patients reported higher incidences of pain,especially acute and persistent pain compared with nonsurgical patients （P 〈 0.05）.Postoperative pain occurred predominately at surgical sites （95.2%） as compared with nonsurgical sites （4.8%）.Agedness,lower education level,surgery,and history of smoking were factors associated with increased duration and severity of postoperative pain and nonsurgical pain （P 〈 0.05）.Conclusions：pain is a common burden of disease in China,of which surgical pain constituted an important component.Surgical patients complained more severe pain than those who did not undergo surgery.Postoperative analgesia still needs to be improved to control pain after surgery.Patients＆#39; perception might influence the efficacy of pain management,which should be implemented with a multidisciplinary approach.

关键词： Inpatients pain Postoperative pain

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Awareness during emergence from anesthesia: Features and future research directions

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World Journal of Clinical Cases 2020年第2期8卷 245-254页

作者： Marco Cascella Sabrina Bimonte Nagoth Joseph Amruthraj anesthesia Section Department of Anesthesia and Pain MedicineIstituto Nazionale Tumori-IRCCS-Fondazione PascaleNapoli 80100Italy Department of Translational Medicine University VanvitelliNaples 80100Italy

The anesthesia awareness with recall(AAWR) phenomenon represents a complication of general anesthesia consisting of memorization of intraoperative events reported by the patient immediately after the end of surgery or at a variable distance from it. Approximately 20% of AAWR cases occur during emergence from anesthesia. Clinically, these unexpected experiences are often associated with distress especially due to a sense of paralysis. Indeed, although AAWR at the emergence has multiple causes, in the majority of cases the complication develops when the anesthesia plan is too early lightened at the end of anesthesia and there is a lack of use, or misuse, of neuromuscular monitoring with improper management of the neuromuscular block. Because the distress caused by the sense of paralysis represents an important predictor for the development of severe psychological complications, the knowledge of the phenomenon, and the possible strategies for its prophylaxis are aspects of considerable importance. Nevertheless, a limited percentage of episodes of AAWR cannot be prevented. This paradox holds also during the emergence phase of anesthesia which represents a very complex neurophysiological process with many aspects yet to be clarified.

关键词： Intraoperative awareness anesthesia awareness with recall Explicit memory Emergence from anesthesia Neuromuscular monitoring Butyrylcholinesterase deficiency

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management of parenteral nutrition in critically ill patients

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World Journal of Critical Care Medicine 2017年第1期6卷 13-20页

作者： Paolo Cotogni Department of anesthesia and Intensive Care Pain Management and Palliative Care S. Giovanni Battista Hospital University of Turin

Artificial nutrition(AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition(PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel "myths" about PN-related complications and show how prevention and monitoring are able to reach the goal of "near zero" PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider:(1) an appropriate blood glucose control;(2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones;(3) the adoption of insertion and care bundles for central venous access devices; and(4) the implementation of a policy of targeting "near zero" catheter-related bloodstream infections. Adopting all these strategies, the goal of "near zero" PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.

关键词： Enteral nutrition Intensive care Nutritional support Vascular access Artificial nutrition

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Thrombotic Thrombocytopenic Purpura in a Parturient Leading to Life-Threatening Thrombocytopenia and Neonatal Demise—A Case Report

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Maternal-Fetal Medicine 2023年第2期5卷 119-122页

作者： Amnon A.Berger John J.Kowalczyk Philip E.Hess Yunping Li Department of anesthesia Critical Care and Pain MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMA 02215USA

Thrombocytopenia is common (up to 12%) in pregnancy;thrombotic thrombocytopenia is a rare cause of thrombocytopenia;however,it is immediately life-threatening to both mother and fetus and requires immediate intervention.This is compounded by the need to act on a presumptive diagnosis with high level of suspicion given the relatively long laboratory confirmation time.A 31-year-old gravida 3,para 1 parturient at 26 weeks of gestation presented to outside hospital with recent onset of easy bruising and blurry vision.A blood count was drawn and showed a platelet count of 19,000/μL.She was transferred to our institution for management where an initial diagnosis of preeclampsia with severe features was made based on thrombocytopenia and fetal growth restriction (anesthesia consult.An urgent hematology consult led to presumptively diagnosing thrombotic thrombocytopenic purpura and cesarean delivery was deferred after discussion with the patient and team.Plasma exchange and steroid therapy were started promptly,and her platelet count improved within 12 hours.Unfortunately,the patient experienced neonatal demise.Undetectable ADAMTS13 levels confirmed diagnosis of thrombotic thrombocytopenia.She was transitioned to rituximab,platelets recovered to baseline,and she continues to do well.Thrombotic thrombocytopenia is a rare,life-threatening cause of thrombocytopenia in pregnancy.Despite grim fetal prognosis,especially in early pregnancy,low threshold of suspicion,early anesthesia involvement,and multi-disciplinary approach can facilitate diagnosis and timely intervention.In our case,it was likely lifesaving.

关键词： Thrombocytopenia Pregnancy Plasma exchange Preeclampsia Fetal death von Willebrand factor Purpura thrombocytopenic idiopathic HELLP syndrome.

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围术期艾司洛尔的安全性：随机对照试验的系统回顾与荟萃分析

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麻醉与镇痛 2013年第1期9卷 38-53页

作者： Savio K H. Yu Gordon Tait Keyvan Karkouti Duminda Wijeysundera Stuart McCluskey Scott Beattie 安博(译) 杜金(校) Department of Anesthesia and Pain Management University Health Network University of Toronto Toronto Ontario Canada

背景尽管发现β受体阻滞剂能够减少围术期心肌梗死（myocardial infarction，MI）的发生，但是β受体阻滞剂导致的低血压与术后卒中和死亡相关。本系统回顾中我们评估了特异性β1-肾上腺素受体拮抗剂艾司洛尔在非心脏手术中的安全性和... 详细信息

背景尽管发现β受体阻滞剂能够减少围术期心肌梗死（myocardial infarction，MI）的发生，但是β受体阻滞剂导致的低血压与术后卒中和死亡相关。本系统回顾中我们评估了特异性β1-肾上腺素受体拮抗剂艾司洛尔在非心脏手术中的安全性和有效性，通过对术后低血压和心动过缓发生率的分析评估安全性，通过对心肌缺血发生率的分析评估有效性。方法我们在电子数据库中检索在非心脏手术围术期使用艾司洛尔的随机安慰剂对照试验。提取设计、人口统计学、血流动力学变化（有计划的或无计划的）、心肌缺血以及心肌梗死的数据，通过荟萃回归评估其异质性来源。结果我们的研究汇集了研究特点完全匹配的67个试验。研究质量受限于小样本并缺乏分配隐匿性的详细说明。总之，分析证明了无计划低血压的发生率增加[OR2．13；95％可信区间（confidenceinterval，CI），1．48-3．04]，并且与剂量相关（R^2=0．408）。未证实心动过缓的发生率有明显增加（OR1．18；95％CI，0．69-2．02）。剂量滴定表现为对动脉血压和心率均有影响。与安慰剂相比，在7项评估研究中艾司洛尔减少了心肌缺血的发生（OR＆17；95％CI，0.02-0．45）。我们没有评估艾司洛尔对心肌梗死和卒中的发生率的影响，因为在检索研究中这些事件极少发生。结论这篇回顾研究表明艾司洛尔能够安全有效地滴定血流动力学至设定的终点。我们还需要对高危患者的安全性数据进行研究，以建立围术期艾司洛尔的安全性和有效性模型。

关键词：随机对照试验艾司洛尔系统回顾安全性围术期荟萃分析血流动力学变化肾上腺素受体拮抗剂

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Effect of Ketamine Instillation on Acute and Chronic Post Mastectomy pain, a Dose Finding Clinical Study

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Open Journal of Anesthesiology 2022年第4期12卷 146-159页

作者： Fatma El Sherif Hany Elmorabaa Khaled Mohamed Fares Sahar Abdel-Baky Mohamed Nourhan M. Elgalaly Khalid Rezk Moaaz Tohamy Department of anesthesia ICU and Pain Management South Egypt Cancer Institute Assiut University Assiut Egypt Department of anesthesia ICU and Pain Management Faculty of Medicine Assuit University Assiut Egypt

Background: Uncontrolled acute postoperative pain is considered a risk factor for the development of chronic pain afterward. Objectives: To explore the most effective dose of ketamine instillation (1 of 3 doses: 1, 2, or 3 mg/kg) for acute and chronic post mastectomy pain (PMP). Methods: Ninety female patients with cancer breast, aged (18 - 60 yrs), weighted (50 - 90 kg), scheduled for modified radical mastectomy, randomly allocated into 3 groups to receive ketamine instillation after surgical homeostasis before wound closure (1 of 3 doses;1, 2, or 3 mg/kg as A, B or C groups respectively) patients were followed up for 48 h for acute pain (total morphine consumption, the first request of analgesia and visual analog scale at rest and movement (VASR/M), chronic pain by Leeds assessment of neuropathic signs and symptoms (LANSS) for six-months, hemodynamics, and side effects. Results: Median total dose of morphine consumption was 8 mg (5 - 10) versus 6 mg (6 - 7) in A and B groups respectively in the first 48 h postoperatively. Lowest VASR/M was recorded in C then B and lastly A group (P = 0.037). No patients in the C group requested analgesia versus thirty (100%) and nine (30%) patients in the A and B groups respectively with the first request of analgesia was 12 h (5 - 36) in the A group versus 30 h (12 - 36) in the B group respectively (P Conclusion: Ketamine instillation effectively controlled acute post mastectomy pain (PMP) in a dose-dependent manner and reduced the incidence and severity of chronic pain in patients who undergoing a modified radical mastectomy.

关键词： Acute pain Breast Cancer Chronic pain Ketamine Instillation Modified Radical Mastectomy

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Diagnosis and management of ophthalmic zoster sine herpete accompanied by cervical spine disc protrusion:A case report

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World Journal of Clinical Cases 2021年第25期9卷 7588-7592页

作者： Giyoung Yun Eunsoo Kim Jiseok Baik Wangseok Do Young-Hoon Jung Chang-Min You Department of anesthesia and pain Medicine Biomedical Research InstitutePusan National University HospitalBusan 49241South Korea Department of anesthesia and pain Medicine Pusan National UniversitySchool of MedicineYangsan 50612South Korea

BACKGROUND Zoster sine herpete(ZSH)can be misdiagnosed because there are no typical vesicular eruptions characterized by a dermatomal distribution.However,incorrect treatment due to a misdiagnosis can lead to severe pain and fatal complications.CASE SUMMARY A 75-year-old woman complained of sudden onset right shoulder pain and atypical headache.After 18 d,sudden hearing loss occurred in the left ear.In serology tests conducted after the onset of hearing loss,varicella-zoster virus IgM was positive.She had no history of a rash or trauma.Under the suspicion of ZSH,antiviral treatment and stellate ganglion block were administered four times,and the pain was effectively controlled.CONCLUSION Early diagnosis and treatment of ZSH can help not only by reducing pain but also by preventing fatal complications.

关键词： Zoster sine herpete Ophthalmic pain Burning pain Ultrasound-guided stellate ganglion block Case report

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骶管布比卡因与布比卡因曲马多用于小儿癌症患者术后镇痛治疗的比较研究(英文)

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The Chinese-German Journal of Clinical Oncology 2013年第3期12卷 118-122页

作者： Mohammed Hegazy Ayman A.Ghoneim anesthesia & pain management Department National Cancer InstituteCairo UniversityCairoEgypt

Objective:Caudal epidural analgesia has become very common analgesic technique in paediatric surgery.Adding tramadol to bupivacaine for caudal injection prolongs duration of analgesia with minimal side effects.The aim of the study was to investigate the different effects of caudal bupivacaine versus bupivacaine with thamadol for postoperative analgesia in paediatric cancer patients.Methods:A prospective randomized controlled trial was conducted over 40 paediatric cancer patients who were recruited from Children Cancer Hospital of Egypt(57357 Hospital).Patients were randomized into 2 groups:bupivacaine group(group B,20 patients) to receive single shot caudal block of 1 mL/kg 0.1875% bupivacaine;tramadol group(group T,20 patients) prepared as group B with the addition of 1 mg/kg caudal tramadol.Results:The mean duration of analgesia was significantly longer among group T than group B [(24 ± 13.7) hours versus(7 ± 3.7) hours respectively with P = 0.001].Group T showed a significantly lower mean FLACC score than group B(2.2 ± 0.9 versus 3.6 ± 0.6 with P = 0.002).The difference in FLACC score was comparable on arrival,and after 2 and 4 hours.At 8 and 12 hours the group B recorded significantly higher scores(P = 0.002 and 0.0001 respectively).There were no significant differences between the groups as regards sedation score [the median in both groups was 1(0-1) with P value = o.8].No one developed facial flush or pruritis.Conclusion:Caudal injection of low dose tramadol 1 mg/kg with bupivacaine 0.1875% is proved to be effective,long standing technique for postoperative analgesia in major paediatric cancer surgery and almost devoid of side effect.

关键词：癌症患者镇痛小儿随机对照试验多用持续时间曲马多副作用

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术前口服普瑞巴林对膀胱癌患者行根治性全膀胱切除术后的镇痛效果(英文)

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The Chinese-German Journal of Clinical Oncology 2013年第3期12卷 113-117页

作者： Ayman A.Ghoneim Mohammed M.Hegazy Anesthesia and Pain Management Department National Cancer InstituteCairo UniversityCairoEgypt

Objective:After the pregabalin has been approved for the treatment of neuropathic pain,preliminary clinical studies suggested a possible role in the perioperative period.To our knowledge,It has never been studied the perioperative analgesic effect of pregabalin in patients with cancer bladder.In this study,we hypothesized that cancer bladder patients undergoing radical cystectomy and received oral pregabalin 75 mg twice daily for ten days preoperatively would get their postoperative pain reduced.Methods:Sixty patients scheduled for elective radical cystectomy were randomly assigned to one of 2 groups(control group or pregabalin group).Patients in the pregabalin group received 75 mg pregabalin twice daily for ten days before surgery.Standard anesthesia protocol was applied to all patients.pain intensity,opioid consumption,level of sedation and other side effects were regularly assessed for 48h postoperative.Results:Mean time for the first request of analgesia was statistically longer in pregabalin group.Meanwhile,mean morphine consumption,VAS scores at rest(in the first 32h postoperatively),VAS scores during movement(in the first 20h postoperatively) were statistically significant lower in the pregabalin group than those in the control group.Patients in the pregabalin group were statistically more sedated in the first four hours postoperative than the control group.Conclusion:Preoperative pregabalin 75 mg twice daily for ten days resulted in 60% reduction in 24h postoperative morphine requirements in patients undergoing radical cystectomy.

关键词：镇痛作用膀胱癌切除术巴林患者围手术期药物用量平均时间

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