Akhtarpersson3904

We describe an evidence-based approach for optimization of infection control and operating room management during the COVID-19 pandemic. Confirmed modes of viral transmission are primarily but not exclusively contact with contaminated environmental surfaces and aerosolization. Evidence-based improvement strategies for attenuation of residual environmental contamination involve a combination of deep cleaning with surface disinfectants and ultraviolet light (UV-C). (1) Place alcohol-based hand rubs on the IV pole to the left of the provider. Double glove during induction. (2) Place a wire basket lined with a zip closure plastic bag, on the IV pole to the right of the provider. Place all contaminated instruments in the bag (i.e. laryngoscope blades and handles) and close. Designate and maintain clean and dirty areas. Smad signaling After induction of anesthesia, wipe down all equipment and surfaces with disinfection wipes that contain a quaternary ammonium compound and alcohol. Use a top down cleaning sequence adequate to redumendations stand on a substantial body of empirical evidence characterizing the epidemiology of perioperative transmission and infection development made possible by support from the Anesthesia Patient Safety Foundation (APSF).BACKGROUND Portal vein thrombosis (PVT) makes the technical aspect of liver transplantation challenging and also affects outcomes. Our aim was to study impact of PVT grade and postreperfusion portal flow on posttransplant outcomes. METHODS Patients who underwent transplantation with PVT between January 2007 and May 2017 were selected (n=126). Data on grade of PVT and portal vein flow were collected. Patients were classified into 2 groups; low grade (Yerdel Grade I, n=73) and high grade (Yerdel Grade II or III, n=53). Using portal flow rate, patients were divided into high flow (≥1000 ml/min, n=95) and low flow ( less then 1000 ml/min, n=31). Additional analyses of flow by graft weight and complications were performed. RESULTS Postoperatively, incidence of biliary strictures were significantly greater in high grade PVT compared to low grade (p=0.02). Incidence of postoperative portal vein thrombosis was higher in low flow after reperfusion compared to high flow (p=0.02), as was bile leak (p=0.02). On identifying factors associated with graft loss, moderate to severe ascites preoperatively, high PVT grade and bile leak were associated with worse graft survival. Subanalysis performed combining grade and flow showed that low grade, high flow had the highest graft survival while high grade, low flow had the lowest (p=0.006). High grade PVT with low flow also appeared to be an independent risk factor for biliary complications (p=0.01). CONCLUSION In conclusion, biliary complications, especially strictures are more common in high grade PVT and graft survival is worse in high grade PVT and low portal flow.BACKGROUND ESBL-E (Extended-Spectrum β-Lactamase-producing Enterobacteriaceae) carriage is frequent among liver transplant (LT) recipients, thereby fostering a large empirical carbapenem prescription. However, ESBL-E infections occur in only 10-25% of critically ill patients with rectal colonization. Our aim was to identify risk factors for post-LT ESBL-E infection in colonized patients. The effect of perioperative antimicrobial prophylaxis (AP) was also analyzed in patients with prophylaxis lasting less than 48 hours and without proven intraoperative infection. METHODS Retrospective study from a prospective database including patients with a positive ESBL-E rectal screening transplanted between 2010 and 2016. RESULTS Among the 749 patients transplanted, 100 (13.3%) were colonized with an ESBL-E strain. 39 (39%) patients developed an infection related to the same ESBL-E (10 pulmonary, 11 surgical site, 13 urinary, 5 bloodstream) within 11 postoperative days in median. K. pneumoniae carriage, MELD ≥ 25, preoperative spontaneous bacterial peritonitis prophylaxis and antimicrobial exposure during the previous month were independent predictors of ESBL-E infection. We propose a Colonization To Infection (CTI) risk score built on these variables. The prevalence of infection for CTI score of 0, 1, 2 and ≥3 were 7.4%, 26.3%, 61.9% and 91.3% respectively. Of note, the incidence of post-LT ESBL-E infection was lower in case of perioperative AP targeting colonizing ESBL-E (p=0.04). CONCLUSIONS 39% of ESBL-E carriers develop a related infection after LT. We identified predictors for ESBL-E infection in carriers that may help in rationalizing carbapenem prescription. Perioperative AP targeting colonizing ESBL-E may be associated with a reduced risk of post-LT ESBL-E infections.BACKGROUND Despite the benefits of ex vivo lung perfusion (EVLP) such as lung reconditioning, preservation and evaluation prior to transplantation, deleterious effects including activation of proinflammatory cascades and alteration of metabolic profiles have been reported. Although patient outcomes have been favorable, further studies addressing optimal conditions are warranted. In this study, we investigated the role of the immunosuppressant drug Cyclosporine A (CyA), in preserving mitochondrial function and subsequently preventing proinflammatory changes in lung grafts during EVLP. METHODS Using rat heart-lung blocks after 1 hour cold preservation, an acellular normothermic EVLP system was established for 4 hours. CyA was added into perfusate at a final concentration of 1 µM. The evaluation included lung graft function, lung compliance and pulmonary vascular resistance as well as biochemical marker measurement in the perfusate at multiple time points. After EVLP, single orthotopic lung transplantation was performed and the grafts were assessed 2 hours after reperfusion. RESULTS Lung grafts on EVLP with CyA exhibited significantly better functional and physiological parameters as compared to those without CyA treatment. CyA administration attenuated proinflammatory changes and prohibited glucose consumption during EVLP through mitigating mitochondrial dysfunction in lung grafts. CyA-preconditioned lungs showed better posttransplant lung early graft function and less inflammatory events compared to control. CONCLUSIONS During EVLP, CyA administration can have a preconditioning effect through both its anti-inflammatory and mitochondrial protective properties leading to improved lung graft preservation which may result in enhanced graft quality after transplantation.Donor derived cell-free DNA in the blood circulation is an early marker of injury in solid-organ transplantation. Here, we review recent evidence that indicates that donor derived cell-free DNA may itself be a trigger of inflammation, thereby adding insult on injury. Early un-resolving molecular allograft injury measured via changes in dd-cfDNA may be an early warning sign, and may therefore enable stratification of patients who are at risk of subsequent allograft injury. Considering dd-cfDNA as a continuous and clinically significant biomarker opens up the potential for new management strategies, therapeutics, and ways to quantify interventions by considering the immunological potential of dd-cfDNA.BACKGROUND Kidneys from small deceased pediatric donors with acute kidney injury (AKI) are commonly discarded owing to transplant centers' concerns regarding inferior short- and long-term posttransplant outcomes. METHODS We retrospectively analyzed our center's en bloc kidney transplants (EBK) performed 11/2007-01/2015 from donors ≤15 kg into adult recipients (≥18 years). We pair-matched grafts from 27 consecutive donors with AKI vs. 27 without AKI for donor weight, DCD status, and preservation time. RESULTS For AKI vs. non-AKI donors, median weight was 7.5 vs. 7.1 kg; terminal creatinine was 1.7 (range, 1.1-3.3) vs. 0.3 mg/dL (0.1-0.9). Early graft loss rate from thrombosis or primary nonfunction was 11% for both groups. DGF rate was higher for AKI (52%) vs. non-AKI (15%) grafts (p=0.004). Median eGFR was lower for AKI recipients only at 1 and 3 months (p4 years follow-up were not significantly different. CONCLUSIONS Small pediatric donor AKI impacted early posttransplant kidney graft function but did not increase risk for early graft loss and decreased long-term function. The presently high nonutilization rates for en bloc kidney grafts from very small pediatric donors with AKI appear therefore unjustified. Based on the outcomes of the present study, we infer that the reluctance to transplant single kidneys from larger pediatric donors with AKI lacks a rational basis as well. Our findings warrant further prospective study and confirmation in larger study cohorts.Although liver transplantation (LT) is the best treatment for patients with localized hepatocellular carcinoma (HCC), recurrence occurs in 6%-18% of patients. Several factors, particularly morphological criteria combined with dynamic parameters, known prior to LT modify this risk and combined in prediction models may be used to stratify patients at need of variable surveillance strategies. Additional variables though likely explain differences in recurrence rates in patients with the same pre-LT HCC status. One of these variables is possibly immunosuppression (IS). Once recurrence takes place, management is highly heterogenous. Within the ILTS Consensus Conference on Liver Transplant Oncology, working group 4 aim was to analyse the data regarding posttransplant management of recipients undergoing LT for HCC. Three areas of research were considered (1) cancer prediction models and surveillance strategies; (2) tailored IS for cancer recipients; and (3) new adjuvant therapies for HCC recurrence. Following formulation of several questions, a literature search was undertaken with abstract review followed by article retrieval and full-data extraction. The GRADE system was used for evidence rating incorporating strength of recommendation and quality of evidence.Liver transplantation (LT) for unresectable colorectal liver metastases has long been abandoned because of dismal prognoses. After the dark ages, advances in chemotherapy and diagnostic imaging have enabled strict patient selection, and the pioneering study from the Oslo group has contributed to the substantial progress in this field. For unresectable neuroendocrine liver metastases, LT for patients who met the Milan criteria was able to achieve excellent long-term outcomes. The guidelines further adopted in the U.S. and Europe were based on these criteria. For hepatoblastoma, patients with unresectable and borderline-resectable disease are considered good candidates for LT; however, the indications are yet to be defined. In the budding era of transplant oncology, it is critically important to recognize the current status and unsolved questions for each disease entity. These guidelines were developed to serve as a beacon of light for optimal patient selection for LT and to set the stage for future basic and clinical studies.Liver transplantation for cholangiocarcinoma has been an absolute contraindication worldwide due to poor results. However, in recent years and thanks to improvements of patient management and treatments of this cancer, this indication has been revisited. This consensus paper, approved by the International Liver Transplant Society (ILTS), aims to provide a collection of expert opinions, consensus and best practices surrounding liver transplantation for cholangiocarcinoma.