الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Anaesthetic managment during orthotopic liver transplantation (OLTx) is faced with many challenges of which, bleeding and haemodynamic perturbations being the most important.
Although the origin of bleeding during (OLTx) is multifactorial, technical difficulties and pre-existing abnormalities of the haemostatic system represent the principal causes of significant perioperative hemorrhages.
Liver cirrhosis is characterized by impairment of primary and secondary hemostasis but it is not clear how this impairment is related to the bleeding problems seen in liver failure. This delicate hemostatic balance can be perturbed by numerous conditions, such as infection/sepsis, which may lead to worsening of coagulation status to date. The role of endogenous heparinoids (with a heparin-like action) in the coagulopathy of patients who have cirrhosis has been demonstrated by thromboelastography with the addition of heparinase I in patients who have recent infection.
Then the introduction of the thromboelastometry in the field of liver transplantation added much in the knowledge of which part of the coagulation system being altered by the disease and consequently changed the transfusion strategies in many centers of transplantation.
Another factor which may alter the management during OLTx is the haemodynamic status of the patient. Patients with ESLD are mostly suffering from hypotension due to many causes. But recently, infection has been shown to cause haemodynamic derangement, with lower systemic vascular resistance (SVR) and higher cardiac output in cirrhotics.
Liver transplant patients suffering from subclinical infection or microbial translocation may experience both haemodynamic and coagulopathic disturbances occuring during (OLTx) affecting also their immediate postoperative course.
Microbial translocation (MT) is defined as the migration of viable microorganisms or bacterial endotoxins (i.e., bacterial lipopolysaccharide (LPS), peptidoglycan, and lipopeptides) from the intestinal lumen to the mesenteric lymph nodes (MLN) and other extraintestinal sites.
Increased MT has been described both in experimental animal models of cirrhosis and in cirrhotic patients. In humans, few studies are available, because of the difficulty in detecting MT to MLN and the lack of widely applicable noninvasive markers of MT.
Detection of bacterial deoxyribonucleic acid (bactDNA) in blood and ascites using the polymerase chain reaction (PCR) has been proposed as a sensitive surrogate marker of MT. Of importance, bactDNA sequence similarity in blood and ascites suggested a shared origin, from a common MT event.
So detecting and excluding infection in cirrhotic patients candidate for transplantation procedures is a mandatory step in the patient preoperative preparation. However, signs of sepsis in such patients may be masked because they have characteristics which make recognition of sepsis difficult.
The aim of the present study was to demonstrate the effect of the presence of bacterial translocation detected by bacterial deoxyribonucleic acid (bactDNA) in blood and ascites using the polymerase chain reaction (PCR) on some haemodynamic and coagulation parameters during a liver transplant procedure.
Also this perioperative study was to correlate the effect of the bacterial translocation on the immediate postoperative morbidity and mortality of liver transplant patients in the intensive care unit.
Thirty consecutive adult patients with grade C liver cirrhosis undergoing living donor liver transplant were enrolled in the study.
A Standardized anesthetic protocol was used. Blood was obtained at the beginning of the procedure from peripherally inserted line for antifactor x assay and for Rotem baseline measurements.
A pulmonary artery catheter was centrally inserted to monitor haemodynamic parameters upon which vasopressors were added accordingly.
According to the absence or the presence of the bactDNA using the PCR technique in the patient samples, they were divided into a negative or positive group.
The demographic data and the hemodynamic parameters recorded were similar in both groups.
The thromboelastometry showed higher readings in the bactDNA positive group than in the negative group. This was similar to that the readings observed during sepsis conditions.
This study revealed that coagulation abnormalities present in cirrhotic patients with positive bactDNA samples may be due to the inhibition of the coagulation process by the same mechanism that occurs during sepsis and not due to the heparin like effect as previously demonstrated.