KC Transplant-Ygun bakimciini rolu

Transkript

27/04/16
EDITORIAL
URRENT
C
OPINION
The intensivist as nosocomial thanatologist
Andrew K. Hilton a and Rinaldo Bellomo a,b
Karaciğer Naklinde Yoğun
Bakımcının Rolü
Fuat H. Saner
complex than the normal diagnosis of disease, in
Intensivists are in a unique position to improve
which the only immediately relevant dimension is
nosocomial end-of-life care (EOLC). They undermedical. Diagnosing dying is a medically informed,
stand the key aspects and limits of vital organ
technology-mediated, social decision.
support; they take into account the effect of specific
The primary diagnosis of dying should be
physiological derangements independent of the
formally considered in the differential diagnostic
underlying diagnosis; and they can explain to
list of all patients who present with severe illness
patients and families what the limits of the techand injury. This is especially important in patients
nology of life support might be in a specific clinical
with multiple co-morbidities, advanced age or poor
situation. Thus, intensivists can guide colleagues,
physical performance. However, the recognition of
patients and their families toward an informed
dying will be influenced by the social and cultural
decision about EOLC.
context. In some cultures, the primary diagnosis of
In many countries, intensivists have also
dying is sometimes perceived as helpful in preventincreased their involvement in managing acutely
ing
deteriorating
ward patients
though
the AND
rapid ICU
ABDOMINAL
AORTIC
SURGERY
S unnecessary, burdensome, painful, futile and
undignified interventions. In other cultures, the
response team (RRT) system. Consequently, they
prevention of death itself is seen as more important.
are now making frequent and often difficult deIn these different cultural and social environments,
cisions about EOLC in the wards outside the ICU.
ICU
Days
for differences
patient characterisdoctors
respond toindominant
social attitudes.perform this relatively common surgery.
As well as the traditional underlying physiological
tics using
multivariate
logistic
regresHowever,
clinical
characteristics
can remain
com-More importantly, our results indicate
and medical
diagnoses, analysis,
the meta-diagnosis
of
In the bivariate
the ICU charfamily differand physi-that ICU organizational characteristics
‘dying’ acteristics
has to be associated
formally considered.
Unfortusion,despite
there specific
was nopatient,
significant
with increased
ICU pelling
cian factors.
nately, the recognition that a patient is dying when
ence
in
in-hospital
mortality
between are related to differences in in-hospital
days included
not
daily rounds
The concept of diagnostic uncertainty applies to
organ support
technology
is having
either available
or in
surgeons
who performed
fewer
than
8 mortality, ICU days, and hospital length
bybean
ICU and
physician
(mean
the
primary diagnosis
of dying as it
does to
any other
place can
difficult
controversial,
andincrease,
characdiagnosis
[6].performed
There is, however,
a uniqueof stay. Such information may provide
terized by
uncertainty
discussed by
Fisher the
in this
and those
who
8 or more
65%;
95% CI,as35%-96%),
having
sur- medical
dimension to this uncertainty [7]. Although the
issue. Accordingly, a decision to withdraw or withcases per
year.
direction regarding ways to further imgeonorgan
or both
the surgeon
ICU phy- diagnosis
of pneumonia may or may not be correct,
hold vital
support
is both and
a medically
Hospitals
that
had fewer
than
36 cases
sician
manage
patient act
vs having
the the risk
that true
pneumonia
will
develop
is neverprovetheoutcomesforpatientswhohave
informed
decision
and athe
negotiated
following
by its diagnosis.
In contrast,
thehad
risk ofhigh-risk operations such as abdominal
discussion
family and
other the
health
providers
of abdominal
aortic surgery
per year
ICUwith
physician
manage
patient
in the increased
dying is increased by the primary diagnosis of dying.
[1–5].
a higher mean in-hospital
mortality
rate
aortic surgery. Because the 5-year rela(mean
increase,
95% CI,
This self-fulfilling prophecy
effect
requires
caution
TheICU
dying
process
can be 39%;
interrupted
at 18%any
Curr. Opin. Crit Care Med, 2013: 19, 613-615
hospitals
that had
36 or more
cases
and having
an application
ICU nurse-patient
inthan
making
the diagnosis
of dying.
Objective
prog-tive survival of aortic aneurysm patients,
stage of55%),
its development
by the
of techTitel
models
for vs
hospitalized
[8] shouldespecially octogenarians, is good and
nology,ratio
thus
making
primary
diagper year
(8%
5%; P = patients
.005). When
of lessthethan
1:2overarching
during the
day nostic
be carefully applied, the limitations of these connosis that ‘the patient is dying’ more difficult.
we
adjusted
for
differences
in
patient
supports surgery,27 strategies to reduce
(mean
increase,
29%;
95%
CI,
1%-68%).
sidered, and the consequences and degree of uncerConsider the following example: An 80-year-old
characteristics
using
multivariate
in-hospital mortality become increasIn dementia
the multivariate
as septic
shown tainty
of the diagnosis
openly
discussed [9]. lopatient with
develops analysis,
pneumonia,
Respect
for a patient’s
wishesthat
andhospia family’singly important.
shock and
renal failure
surgery
for a fractured
regression,
we found
in Table
4, theafter
ICU
characteristics
in- gistic
wishes
does
not
simply
imply
that
the
family
alone
neck of femur following a fall in a nursing home.
Daily rounds by an ICU physician
dependently associated with in- tals that had fewer than 36 cases per
This patient could be considered to have sepsisdaysdysfunction
for abdominal
aortic year had a significantly higher in- were associated with a 3-fold reduction
inducedcreased
multipleICU
organ
syndrome,
a
Department
of Intensive
Care, Alfred
Hospital
and bhospitals
Australian and Newin in-hospital mortality for abdominal
necessitating
vasoactive
medications,
replacehospital
mortality
rate
than
surgery
cases included
notrenal
having
daily Zealand
Intensive Care Research Centre, School of Public Health and
ment therapy and mechanical ventilation. Conthat had
36 Monash
or more.
As Melbourne,
shown Victoria,
in Table
Medicine,
University,
Australia aortic surgery patients. This finding is
rounds by an ICU physician (mean in- Preventive
versely, this frail patient with advanced dementia
Correspondence
to Rinaldo
Bellomo,
and New Zealandconsistent with an emerging body of evi4, hospital
volume
alsoAustralian
was inversely
crease,
95%
CI, 48%-126%),
and Intensive
could simply
be83%;
‘dying’.
Therapeutic
intervention
Care Research Centre, School of Public Health and Preventive
may postpone
not prevent ratio
it. In of
this
associated
in-hospital
af- dence that suggests using full-time inhaving death,
an ICUbut
nurse-patient
less Medicine,
Monash with
University,
Alfred Hospitalmortality
Campus, Commercial
setting, the diagnosis of dying is made in the hierVictoria,
Tel: +61 3in
9496
5992;
fax: +61tensive care physicians can reduce interMelbourne,
adjusting
forAustralia.
differences
both
ICU
than 1:2 during the day (mean in- 3Road,
9496 3932; e-mail: [email protected]
archical preference to that of septic shock because
and
characteristics.
hospital mortality.28,29 We found that
crease, of
49%;
95%severe
CI, 17%-91%).
Curr
Opinpatient
Crit Care 2013,
19:613–615
of the presence
chronic,
and progressive
daily rounds by an ICU physician were
cognitive decline. Diagnosing dying is much more
DOI:10.1097/MCC.0000000000000035
• 
Thantalogist: Ölüm üzerine araştırma yapan, interdisipliner bir girişim
• 
Yoğun Bakım Hekimi:
•  Organ destek (KC, böbrek, akciğer) tedavisinin anahtar noktasını
anlar
•  Teknik destek tedavinin kısıtlılıklarını bilir
•  End-of-life-care kararını tüm hekimler arasında en iyi bilir
•  Büyük sorumluluk
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie
Direktor: Prof. Dr. med. A. Paul
Hospital and Surgeon Volume
1070-5295 ! 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
Surgeons who performed fewer than 8
Yoğun Bakım Uzmanının Sağ kalım üzerine etkisi
dominal
aortic surgery
patients andEtkisi
sig- likely affect but were not associated with
mortality
rate than surgeonsSağ
Yoğunhospital
Bakım
Uzmanının
kalım
Üzerine
who performed 8 or more (10% vs 5%; nificant variation in ICU organizational reduced risk of surgical complications.
P = .003). However, when we adjusted
• 
Gözlem çalışması, Maryland eyaletinde 46 adet aortik anevrizma
tedavisi uygulanan klinik katılmış
• 
Tarih: 1994-1996
• 
Yapılan ankete YBÜ‘leri başkanlarının %85’i katılmış
COMMENT
associated with reduced risk of several
This study demonstrateswww.co-criticalcare.com
that there is sig- specific medical complications and in-
Copyright
© per
Lippincott
Williams
& Wilkins.
article isofprohibited.
variation in of
thethis
outcomes
ab- terventions that an intensivist would
cases
year had
a higher
meanUnauthorized
in- nificantreproduction
characteristics in Maryland hospitals that
Table 3. Risk of Postoperative Complications With No Daily Rounds by an ICU Physician for
Abdominal Aortic Surgery Patients in Maryland, 1994-1996*
Complications
Patients With
Complication, %
OR (95% CI) of Without vs
(n = 2606)
With Daily Rounds of ICU Physician
Medical complications
Pulmonary insufficiency after procedure
Cardiac complications after procedure
11.8
10.8
1.9 (0.5-7.8)
1.4 (0.7-2.4)
Acute renal failure
4.7
2.2 (1.3-3.9)†
Septicemia
3.4
1.8 (1.2-2.6)†
Acute myocardial infarction
2.6
1.4 (0.7-2.8)
Daily rounds by an ICU physician may
be a marker for team care, and this model
can be widely applied because our results were not predicated on the presence of residents. Our study is unique because we evaluated mortality in a highrisk population, adjusted for differences
in comorbidity and severity of illness,
used multilevel modeling, and included data from 2606 patients from 39
hospitals, which provided us with the statistical power to detect clinically significant associations between organizational characteristics of ICUs and
outcomes. Previous studies have had less
power for detecting differences because
they included many patients with a relatively low risk of in-hospital mortality
and adjusted for differences in risk across
patient populations, which may distort
the relationship between ICU organizational characteristics and outcomes.1,3,30
We also found that variation in organizational characteristics of ICUs was
associated with differences in resource use for patients undergoing ab-
Yoğun bakım uzmanı olmayan YBÜ’de
Mortalite riski üç kat artıyor (OR 3.0)
Cardiac arrest
Surgical complications
Surgical complications after procedure‡
Surgical E codes§
Interventions
Reintubation
Reoperation for bleeding
Platelet transfusion
1.2
2.9 (1.2-7.0)†
8.6
0.3
1.5 (0.8-2.0)
4.3 (0.9-20.0)
14.1
2.4
2.0 (1.1-4.1)†
1.1 (0.5-2.6)
2.0
6.4 (3.2-12.4)†
*The complications associated with increased in-hospital mortality in abdominal aortic surgery patients were included
in this analysis. For each complication, the multivariate model is adjusted for age, sex, race, ruptured/unruptured
aneurysm, elective/urgent/emergent admission, comorbid diseases in Romano-Charlson index, hospital volume, and
surgeon volume. ICU indicates intensive care unit; OR, odds ratio; and CI, confidence interval.
†Data are statistically significant at P,.05.
‡Defined as hemorrhage during a procedure (ICD-9-CM code 9981), accidental laceration during a procedure (ICD9-CM code 9982), or disruption of operation wound (ICD-9-CM code 9983).
§Surgical E codes are used to identify environmental events, circumstances, or conditions as the cause of an injury.
1314
JAMA, April 14, 1999—Vol 281, No. 14
Pronovost, JAMA, 1999: 281: 1310-1317
Titel
KC Transplantasyonu: YoğunSeminar
Bakım Uzmanının Rolü –
Fulminan Hepatik Yetmezlik
Survival (%)
ALF transplantation
N-acetyl cysteine
RRT
61
56
47
Hemodialysis
19
99
-2
00
3
20
04
-0
8
19
94
-9
8
19
89
-9
3
19
79
-8
3
Beds (n) 2
Intensivist Staffing (n)
19
84
-8
8
Years
19
73
-7
8
Transplantasyondan sonra
FHY sağ kalım
çeşitli dönemlere göre değerlendirme
JOURNAL
OForanı:
HEPATOLOGY
Operating as a high-volume centre for the care of patients
etylcysteine, and intervention studies showed
h liver disease, it has developed a multi-disciplinary approach
100
rovements in systemic and cerebral haemodynamics
are
of these
patients
as such has
a unique opportunity to
106,107
oxygen
uptake.
Aand
multicentre
double-blind
108
uate
the
evolution
of care andinchanges
in the nature and outomised
trial
of N-acetylcysteine
non-paracetamol
thefailure
illnesswas
overcompleted
time. In this
we of
analysed80data of77
ee of
liver
afterstudy,
8 years
uitment.
N-acetylcysteine
wasliver
welldisease
tolerated
and
3305 patients
with acute
admitted
to the LITU74
with improved
non-transplanted
rciated
the period
1973–2008,
seeking to survival,
evaluatebut
and quantify the62
60
in patients
treatedcare
earlysupport
in the course
of disease
and
cts
of intensive
and the
introduction
and refinelow-grade
encephalopathy.
nt of ELT. We sought also to delineate the changes in disease eti-55
y and severity that had occurred over time, and how
40 these
phalopathy and ammonia
ted
to the clinical complications and outcomes observed.
38
acute liver failure, hepatic encephalopathy
Before December, 1984 (24)
January, 1985 to December, 1989 (482)
5 2000 to
6 December,
102004 (1713)
January,
1
2 3
15
4
51
44
Continuous hemofiltration
mpasses many neuropsychiatric disturbances,
25
25
20
ing from
confusion and disorientation to
ents
and minor
methods
ICH therapy
Mannitol
30% NaCl
k coma and cerebral oedema, resulting in
acranial hypertension. Although the frequency of
nts and dataset
0
cally overt cerebral oedema has decreased over the
Fig. 1. Schematic evolution of care for patients with ALI/ALF at the Liver
0
1
2
3
4
5
6
7
8
9
10
20 years, such hypertension still accounts for
Intensive Therapy Unit,
Kings College Hospital. ALF; acute liver failure, RRT;
Years
analysis is based
on all patients aged P16 years admitted to the LITU
renal replacement therapy, ICH; intracranial hypertension.
25%
of deaths.8 Survival
without transplantation for
een 1973 and 2008, with a diagnosis of acute liver injury (ALI) or ALF. Incluents with acute liver failure is poor in those with Figure 3: Survival after liver transplantation for acute liver failure by date of surgery in Europe, 1984–2008
criteria for ALI included: (1) an INR of P1.5; (2) absence of a previous
history
Bernal, Lancet, 2010; 376, 190-201
from the
European liver transplant registry. Numbers are completed 1, 5, and 10-year survival rates.
re
encephalopathy, and the risk of substantial Data
linical/radiologic findings of liver disease; and (3) illness 626Numbers
weeks in
ofparentheses
duraare surgeries done in each group.
Bernal, J Hepatol, 2013: 59, 74-80
bral
and
intracranial
hypertension (HE
is grade P2) [11] at
Thoseoedema
who had or
developed
overt encephalopathy
All patients developing ALF with overt HE with agitation or coma were intutest
thosetheir
withhospital
hyperacute
or acute
presentations.
In view
of the closebated,
relation
between blood ammonia
ime in
during
stay were
classified
as having ALF [12].
Transfer
Titel sedated, and mechanically ventilated. Sedation was initially with moratients
withconsidered
subacute in
disease,
evenreferred
the presence
of andconcentrations
cerebral
complications
of acute
e LITU was
all patients
with ALF
in those with and phine
and
midazolam
and with
routineund
use of
paralysing agents, with evolution
Klinik
für
Allgemein-,
ViszeralTransplantationschirurgie
hepatic
encepha
lopathy
suggests
critically
failure, treatments
reduce
con- with rare use of paralysis. In these cases,
fest
there
were features
raising
prognostic
concern,
including liver
hypoglycaemia,
to usethat
of fentanyl
andammonia
propofol infusions
hepaticliver
organfunction
failure orthat,
progressive
coagulopathy
with ancentra
INR >2
or PT
aired
although
infrequently
tion
could interrupt
of regular
hepaticclinical assessment and non-invasive techmonitoringprogression
for ICH utilized
. All patients
with subacute
disease and any
or evidence of
ciated
with intracranial
hypertension,
is acoagulopathy
sign of encephalopathy
or niques,
development
intracranial
with direct of
ICP monitors
first selectively used in 1977. In 2008, 13 of
goutlook.
liver volume were considered for transfer [13].
42 (31%) concentrations
patients ventilated with
hypertension. Ammonia
in overt
the HE had ICP monitors inserted.
atients
were identified
throughencephalopathy
the admission diaries
of the LITU
which form
a
Treatment
for ICH crises
was initially with bolus intravenous mannitol and
e pathogenesis
of hepatic
in acute
circulation
point
to the complex
interorgan
metabolism
nuous record since the unit first opened. Clinical data was derived from archived
increased
sedation
with
use
of
thiopentone
in refractory cases. Continuous intrafailure is only partly understood, but clinical and that occurs in liver failure. Ammonia is primarily
ds (1973–99) and after 1999 from the prospective LITU electronic database.
venous
infusion
of
hypertonic
saline
rimental evidence suggests an important role for produced in the small bowel from glutamine,(30%) was introduced for all ALF patients in
he dataset collected comprised patient age, gender, contemporaneous etiol2001 and also used as bolus therapy for ICH, with mannitol and indomethacin for
ed
concentrations of circulating neurotoxins, metabolised by glutaminase to ammonia and
and laboratory test results (INR, bilirubin, creatinine and sodium) on admissecond-line use. Active temperature management was introduced in patients
109
118,119
cially
ammonia.
Results
is converted to urea by the
to the LITU.
Over the study
period, from
changeslaboratory
in laboratoryglutamate.
methods were Ammonia
with severe HE in 1999, with a target of 36 !C and greater degrees of hypothermia
110–112
ies
liver, but in reserved
liver failure
concentrations
rise, to medical agents [8,14].
have
shownupon
ammonia-induced
changes
in healthy
ely to have
impacted
these values. Etiology
was classified
into paracetfor those
with ICH refractory
an alternative pathway
for detoxifi
cationcysteine
in muscle
roand
trans
mitter synthesis
and
release,
neuronal
non-paracetamol,
and the
latter
subclassified
into viral,and
non-paracetaIntravenous
N-acetyl
(NAC) was administered to all patients after
drug-induced,
pregnancy-related
and ‘other’
etiologies.
latter group
becomes
available, 1989.
in which
synthetase
ative
stress, impaired
mitochondrial
function,
and The
If theyglutamine
had not received
a loading bolus dose prior to LITU admission,
120
ded cases
resulting from
autoimmune
Budd-Chiari
syndrome,
metabolises
ammoniapatients
back towere
glutamine.
otic
disturbances
resulting
fromdisease,
astrocytic
initially administered 150 mg/kg over 15 min and all received an
gnancy,
Amantia to
fungi,
Wilson’s disease,
and specific The
hepatotoxins.
infusion ofmight
100 mg/kg/24
for a maximum of 5 days or until the INR was <2.
abolismischemia,
of ammonia
glutamine.
The overall
drug ornithine aspartate
aid this hconversion
sltwere
as in
indeterminate
if none ofand
theseastrocytic
causative factors
presInitially,agent
intravenous
antibiotics
is aclassed
change
cerebral function
and were
represents
an attractive
for reduction
of were administered to all patients after
Patients
with liver dysfunction from primary 113–115
or following
admission,
but useeﬀ
was
reduced
ling.109,111,112
circulating
ammonia,
and seems
ective
in over
the time with current restriction to patients
Findings from clinical studies systemic
havesepsis
tectomy were not included in this analysis.
established HEin
or chronic
other organ
dysfunction, those fulfilling or likely to fulfil
encephalopathy
liver
gested a link between the development of high treatment of hepaticwith
he presence or absence of overt encephalopathy and the requirement for
intutransplant criteria and to those 122
without HE but with clinical signs of significant
121
es of hepatic encephalopathy and arterial ammonia disease. However, a large randomised trial
of
n and ventilation were documented as was placement of intracranial pressure
systemic inflammation in the absence of confirmed sepsis [8,15].
entrations.
However,
althoughas intracranial
hyperornithine
aspartate in Indian patients with acute liver
monitors.
Patients
were classified
having ICH if in
their clinical
course they
ion pupillary
probablyabnormalities
represents(dilated
the (>6
most
severe
failure
did tonot show improvements in ammonia
loped
mm) and
sluggishly
reactive
Liver transplantation
other
than(in
ammonia
seem
to be concentration,
),ifestation,
a sustainedfactors
ICP of P25
mmHg
those with
ICP monitoring),
requirement hepatic encephalopathy, or survival
ortant in hepatic
encephalopathy
pathogenesis.
with placebo. Glutamine might be converted
herapeutic
intervention
or at autopsy had
evidence of gross CE.compared
Clinical records
first liver by
transplant
for ALFin
was
ot
permit
collection
of
comprehensive
data
in
respect
of
infection
incidence
or
vere hepatic encephalopathy and cerebral oedema back to glutamate
andThe
ammonia
glutaminase
theundertaken in 1984, and a total of 387 were
123 period. After 1990, all cases were selected using nationoverdisease.
the study
iotic
those who
fulfilled poorstates,
prognostic
KCC criteria
but were
to administration,
arise in systemic
inflammatory
often
gut, kidneys,
liver, andperformed
brain in this
Alternative
©1999 American Medical Association. All rights reserved.
Pronovost, JAMA, 1999: 281: 1310-1317
Titel
Downloaded From: http://jama.jamanetwork.com/ by a UNIVERSITAET DUISBURG ESSEN User on 01/25/2016
Model for End-stage Liver Disease (MELD)
Karaciğer yetmezliğini değerlendiren skor – Child-Pugh Skoru’nun yerine geçti
Kolay hesaplanan bir skor
3 “objektif” Laboratuar değeriyle [ INR; Kreatinin; Bilirubin ]
Ulusal bekleme listesinde 3 –ay sağ kalım oranıyla korelasyonu var
12/2006’dan beri Almanya’da karaciğer sunumu MELD skoruna
göre uygulanıyor
129
Titel
1
27/04/16
ET Bölgesinde Transplant Olan Hastaların Match MELD Değerleri
01/2007- 09/2013
MELD’e Bağlı Operasyon Riski
% 3-Month Mortality as a Function of MELD
Transplant sonrası en iyi sonuç
veren MELD skoru
100
90
80
60
50
Almanay‘da organ kabul
edildiğinde ortalama MELD
40
30
20
10
0
-20
-10
0
10
20
30
40
50
60
70
80
MELD Score
MELD
Eurotransplant Leiden 2013
Titel
Titel
Beyin Ölümü Olan Donörler/ Donor Risk Index:
Eurotransplant ve UNOS Karşılaştırması
UNOS
ET
DRI > 1.5
32%
63%
DRI > 2
6%
23%
Karaciğer Nakli ve Yüksek MELD
Infeksiyon
Diyaliz
Originalarbeit
35
60
§  Dialysis
§  No diaylsis
40
P = 0,001
30
20
Number of patients
60
Abb. 6 Donor-Risk-Index (DRI) von postmortalen
Leber-Spendern im Eurotransplant-Bereich vs.50UNOS
(nach Braat A et al. [20]).
Number of patients
50
40
30
P=0,004
20
No infection
Infection
10
10
0
<20
0
<20
21-30
21-30
31-40
MELD
31-40
MELD
LTX Patients Essen 1/2011-12/2011
Schlitt, Z Gastroenerol 2011; 49:30-38
Titel
“Kronik-Üzerine Akut KC Yetmezliği”
Titel
Abb. 7 Entwicklung der Lebendspende zur Lebertransplantation im Eurotransplant-Bereich, und davon in Deutschland (1995 – 2009).
Siroz Hastaları – Mekanik Ventilasyon ve Sağkalım Oranı
Herhangi bir olay
ACLF
Karaciğer
destek
sistemleri ??
Heruntergeladen von: Universität Duisburg - Essen. Urheberrechtlich geschützt.
% Mortality
70
Siroz
İnflamasyon
Mekanik ventilasyon
gereken siroz
hastaları
N = 246
tigt werden, wobei hier die 1-Jahres-Überlebensrate sogar nur
75,8 % betrug. Hierbei konnte gezeigt werden, dass die VerYBÜ sağ olarak
YBÜ‘de ölen hasta
schlechterung des Überlebens fast ausschließlich durch die
taburcu
sayısı
Transplantation von Patienten mit einem labMELD-Score von
N = 84 (34.1%)
N = 162 (65,9%)
MOF
Kısmen iyileşme
über 30 zustande kam. Während das 1-Jahres-Überleben in
den MELD-Score Gruppen < 10, 10 – 20 und 20 – 30 bei 84,5 %,
Diskussion
83,4 % und 78,6 % lag, war es in der Gruppe > 30 bei nur 52,6 %.
!
Damit stellen sich anhand dieser Studie die Ergebnisse sogar
Während die Lebertransplantationszahlen in Deutschland über
noch schlechter dar als in der Analyse der ET-Daten, die für 1-yıl transplant
1 yil içinde ölen
LTX
diese Gruppe (inkl. Retransplantation) ein 1-Jahres-Überleben
die letzten 10Transplant
– 15 Jahre leicht
gestiegen
sind,
persistiert
das
olmadan sağ kalan
hasta sayısı
Ölüm
?
n = 10
von knapp über 60 % dokumentiert. Ob diese Unterschiede
Problem des gravierenden Mangels an postmortal gespendeten
N = 17
N = 57
durch die Zentrumsauswahl oder durch inkomplette DokuOrganen. Mit der Einführung der MELD-basierten Leberallokamentation in den Analysen zustande kommen, bleibt letztlich
tion im Dezember 2006 konnte zwar das geplante Ziel einer
unklar. Eindeutig zeigt sich jedoch eine deutliche Verschlechteniedrigeren Mortalität
auf der Warteliste zur LebertransplantaLevesque, J Hepatol 2014, 60: 570-578
Titel
Titel
Klinik
für Allgemein-,
ViszeralKlinik für Allgemein-, Viszeral- und Transplantationschirurgie
rung der Ergebnisse der Lebertransplantation seit Einführung
tion erreicht
werden
– de facto wurde
sie und
von Transplantationschirurgie
20 auf 10 % halder MELD-basierten Allokation.
biert. Die Ergebnisse nach Lebertransplantation haben sich
Während kurz nach MELD-Einführung die mittleren matchjedoch deutlich verschlechtert. Untersuchungen von WeismülMELD-Scores der transplantierten Patienten in Deutschland
ler et al. konnten bereits 2009 zeigen – allerdings in einer
bei 25 lagen – und aus diesem Zeitraum stammen die o. g.
unizentrischen Evaluation –, dass das 1-Jahres-PatientenüberAnalysen –, hat sich der mittlere matchMELD-Score bei Allokaleben direkt nach Einführung der MELD-basierten Allokation
tion inzwischen auf 34 erhöht. Dies bedeutet, dass damit nun
von knapp 90% auf unter 80%, also rund um 10% abgenomvorwiegend Patienten in sehr schlechtem klinischem Zustand
men hat [15]. Diese Ergebnisse konnten auch in einer multitransplantiert werden. Dies lässt befürchten, dass sich dadurch
zentrischen Analyse basierend auf 7 deutschen Zentren bestä16,5 Mio. Einwohnern 3 Zentren (entsprechend 1,8 Zentren/10
Mio. Einwohner). Das Vereinigte Königreich verfügt über 8 Zentren bei ca. 61 Mio. Einwohnern (entsprechend 1,3 Zentren/10
Mio. Einwohner).
Schlitt HJ et al. Aktuelle Entwicklungen der… Z Gastroenterol 2011; 49: 30 – 38
2
27/04/16
Olgu 1
• 
64 yaşında hasta
• 
NASH-Siroz, BMI: 33 kg/m2
• 
Hidropik dekompanse
• 
HRS => diyaliz gerekiyor
• 
Olgu 1
Intraop: 4 Eks, 10 g fibrinojen, 3000 I.E. PCC, 2 TK, 2000 ml Kristaloid
Noradrenalin: 0,6 µg/kg/min
Postop: diyaliz (CVVHD) postop 5. güne kadar
Postop 4. gün : hasta ekstübe oluyor
MELD 40
• 
2 damar koroner yetmezliği => miyokard enfarktüsü geçirmiş =>
ACVB 2009
• 
PT 17% (INR 3.7), aPTT ≥ 170 sn., fibrinojen < 50 mg/dl, PLT 48/
nl
• 
SCr 4,4 mg/dl, Bilirubin 22,4 mg/dl
mekanik ventilasyon süresi: 125 saat
Titel
Titel
Annals of Surgery ! Volume 259, Number 6, June 2014
Olgu 2
Yoğun Bakıma Kabul Olan Siroz Hastaları
SD
Complicated gastrointestinal bleeding
9%
Prediction
Model of Futile Outcome
(encephalopathy, aspiration, or shock)
utility
are shown in Table 2. During MICU stay,
vasopressors, mechanical ventilation, and
RRT were required in 51%, 62%, and
19% of cases, respectively.
Uncomplicated gastrointestinal bleeding
8%
The
multivariate
analysis (Table 4)4%
identified MELD score,
Isolated acute
renal failure
Other
7%
Finalrisk,
diagnosisage-adjusted CCI 6 or more, and pre-OLT septic shock
cardiac
Complication of cirrhosis
40%
Outcome and Causes of Death
Gastrointestinalpredictors
bleeding
as independent
for futility (Fig.23%
3), with greatest risk from
Acute alcoholic hepatitis
4%
Survival rates in the MICU, in the hosSpontaneous bacterial
peritonitis
7%
cardiac disorders
(OR:
3.14) and age-adjusted
CCI 6pital,
or and
more
(OR:
6 months
after MICU admission
Isolated hepatic encephalopathy
5%
were 59% (95% CI, 50%– 67%), 46%
Hepatorenal syndrome
1%
3.95). Using
4 factors,
of this
model had a
Acute diseaseall
not related
to cirrhosis the futility prediction
60%
(95% CI, 38%–54%), and 38% (95% CI,
Pneumonia
16%
30%–
47%),
respectively
(Fig. 1). Most
c-statistic
of
0.754.
A
futility
score
of
26
or
more
identified
patients
Other infection
14%
deaths occurred in hospital, and the
Status epilepticus
7%
with a high
futility risk defined by a 50%
at 3survival
months
Cardiac failure
7% death rate
6-month
of the patients disOther
16%
charged alive from the hospital was 86%.
after OLT, whereas patients with scores of 22 or less had
an
excellent
Death in the MICU was attributable to
Findlay,
Liver
2011, 496-510
the persistence
orTransplantation
aggravation of the initial
3-month survival rate of 93% (Table 5). The model predicted
futility
disease
in Care
79% ofMed
cases2010,
(multiple
organ
Crit
2108-2116
graphic variables (age, gender), comorbidities, ther individually if they were not used for SOFA Das,
Titel 30%, and 50% for patients with scores of 20, 25, and 28
risk
of 10%,
functional status, admission (direct), variables calculation (degree of ascites, albuminemia, INR, failure, 60%; brain lesions, 10%; refractory
shock, 9%) or to a secondary complication
Klinik
für
Allgemein-,
Viszeralund
Transplantationschirurgie
on
diagnosis
(direct
complication
of
cirrhosis
or
natremia)
or
as
components
of
the
SOFA
score.
(Fig.
4).
not, infection on admission), characteristics of
To identify which score had the best discrim- in 21% of cases (bleeding, 11%; nosocomial
9 patients, 37 patients (22%) had a futile postll in-hospital, with 18 patients (49%) and 32
at 1 and 3 months. Patients with futile (n =
= 132) outcomes were comparable in terms of
d donor characteristics (Table 2), underlying
), and operative variables (Table 3). The donor
for the futile and nonfutile groups (DRI 1.58
26%). Although the MELD scores were comps, recipients with futile outcomes had greater
y, including a higher proportion with increased
14%), age-adjusted CCI 6 or more (43% vs
atment (97% vs 87%), and pretransplant septic
sofsurgery.com
YBÜ süresi: 12 gün
Klinikte kalma süresi: 45 gün
shock (32% vs 18%). Allografts of patients with futile outcome had a
analysis, 101 patients were alive and 68 paYBÜ kabul olan siroz hastalarının %40 kadarı sepsiste ve/veya septik şok tedavisinde
higher degree of graft injury (alanine aminotransferase 1068 vs 562
wn causes of death included infection/sepsis in
U/L)
a higher
fraction
ofunit
initial
30%)
rdiovascular causes in 18 patients (26%), liver
Table 1. and
Characteristics
of patients
on intensive care
admissionpoor function (49%
had vs
cirrhosis.
Elevenand
patients with previous
transplantation
and three patients
nonfunction (16% vs 3%). At the timeValue
of (Mean
analysis,
31liver
patients
in the
24%), multiorgan failure in 5 patients (7.3%),
"
whose charts had been lost were excluded.
Characteristics
or Percentage)
nonfutile group
(23%) were dead. Hepatic
failure was
the138cause
of included. Their
atients (2.9%), and causes were unknown in 4
Finally,
patients were
characteristics are shown in Table 1.
Male (%)
68%
death Knaus
in 22%
of futile
recipient Patients
groups,
with
median follow-up time for living patients was 47
scale (autonomy):
A/B/C/D and 26% of nonfutile
28%/48%/23%/1%
were admitted directly from
Charlson score (comorbidities)
" 1.4
the emergencygroup
department in 43% of
recurrent
C (89%) as the leading1.02
cause
in the nonfutile
-, 3-, 5-, and 8-year graft and patient survivals
Cause ofhepatitis
cirrhosis
cases and from the ward or liver ICU in
Alcohol with or without viral hepatitis
78%
and nonviral
failure (87%) in the futile
(24%
vs was present on
%, and 53%, and 72%, 64%, 60%, and 56%,
Pure viral B graft
or C hepatitis
16% group. Cardiac
57% of cases.
Infection
Other
6%
MICU admission in 56 patients (41% of
Current
alcohol abuse (in patients
6%) and
infectious
(38% vs 29%) causes of76%death werecases)
more
frequent
. The posttransplant death rate was highest at
and was microbiologically docuwith alcoholic cirrhosis)
mented in 40 patients (71% of cases).
Reason
for intensive
care unit admission
in futile
than
in
nonfutile
groups.
after OLT and 5% and 3% for the second and
Isolated acute respiratory failure
27%
Values for clinical and biological charIsolated coma
23%
ars (Fig. 2B).
acteristics defining severity on admission
Shock " multiple organ failure
22%
nsplantation in patients with MELD scores
verall graft and patients’ survival for adult
tory MELD scores of 40 or more (n = 169)
ansplantation. B, The annual death rate for
The death rate was 0 for the posttransplant
a were analyzed for the period from the
he MELD allocation system (February 27,
er 31, 2010. Patients with acute liver failure
splantation were not included.
Postop 5. gün.: katekolaminler tamamen kesiliyor
cirrhosis (cause of cirrhosis, severity as assessed
with D’Amico’s classification, degree of ascites,
albuminemia, INR, natremia), and organ failures. The SOFA score was computed because it
exclusively assesses organ failures and thus has a
clinical meaning. On the contrary, the ChildPugh and MELD/MELD-Na scores were not included in the analyses because their clinical
meaning, when computed on ICU admission, is
questionable in the ICU setting. For example,
the Child-Pugh score is computed from variables
linked with organ failures (bilirubinemia, degree
of encephalopathy) and portal hypertension (degree of ascites) and from albuminemia, which, in
the ICU setting, results not only from liver failure but also from hydration, capillary leak, and
nutritional status. The Simplified Acute Physiology Score II score is also computed from variables linked with demographic characteristics,
history, organ failures, and reason for admission.
Including the Child-Pugh, MELD/MELD-Na,
and Simplified Acute Physiology Score II scores
in the analyses, because they share common
components with the SOFA score (creatininemia, bilirubinemia), would have created unwanted correlations between the predictors. Instead, we included in the analyses the individual
components used to compute these scores, ei-
ination capacity to predict inhospital mortality,
receiver operating characteristic curves were
constructed and areas under receiver operating
characteristic curves (AUROC) were compared
(36). All available scores calculated on day 1 were
tested for their capacity to predict death for the
entire cohort. For patients still alive on day 3,
AUROC values for the SOFA score and the number
of organ failures were also calculated after 3 days.
For the two scores with the best discrimination
capacity, values associated with a very high probability of death (!80%) were determined (37). A p
value !.05 was required for statistical significance.
The study was approved by the Ethics
Committee of the Société de Réanimation de
Langue Française and received the required
legal approval from the appropriate French
data protection committees. According to the
French regulation on research performed on
data, usual informed consent was waived and
replaced by information provided to patients.
• 
50 yaşında erkek hasta
• 
MELD 28
• 
Primer sklerozan kolanjit (PSK) siroz
• 
Tekrarlayıcı kolanjit geçiriyor (Candida alb ve VRE dahil)
• 
Kliniğe kabul edildiğinde diüretikle kontrol edilemeyen asit=> 6 kez
Prometheus tedavisi uygulanıyor
• 
4 MRGN (karbapeneme dirençli Enterbactereocea) rektal
kolonizasyonlu
• 
Pnömoni nedeniyle 1 hafta mekanik ventilasyon gerekiyor => iyileşiyor
• 
4 aydır Klinikte, bugüne kadar 2 defa YBÜ tedavisi görmüş
Titel
infection, 5%; other, 5%). Death in the
MICU was preceded by a written decision to
limit or withdraw life-sustaining treatments in 65% of cases.
Long-term Outcome of Nonfutile Patients
The 132 patients in the nonfutile group had overall 1-, 3-, 5-,
Inhospital
and 8-year survivals of 89%, 79%, 75%, and 69%. TheRisk
CoxFactors
modelforfor
Mortality Assessed on Day 1
graft failure/mortality-free survival identified recipient The
age,
postopresults of the univariate analysis
are presented
in Table 3. Of note is that
erative grade 4 complications, hepatitis C, and metabolic
syndrome
the liver disease severity staged according
as independent survival predictors (Table 4). The Harrells
c-statistics
to D’Amico’s
classification did not correlate with inhospital
mortality.
of this model was 0.720. Patients with metabolic syndrome
had poor
Because hematologic failure was not associated with mortality, a modified SOFA
long-term survival (Fig. 5D).
LT in highest AcuityDISCUSSION
Recipients
• 
• 
• 
• 
score, excluding points for hematologic
failure, was computed. The following factors were included in multivariate analysis:
age, infection, secondary admission from a
unit different from the emergency department, serum albumin, degree of ascites,
INR, and modified SOFA score. After backward elimination, age older than 50 yrs,
lower serum albumin, higher INR, and
higher modified SOFA score remained independently associated with inhospital
mortality (Table 4).
This is one of the first studies to analyze outcome variables for
liver transplant recipients with
the highest MELD scores (≥40) at the
RESULTS
Ntime
= 169
hasta
≥ 40 acuity of these extremely sick patients
of OLT.
TheMELD
high medical
Patient Characteristics
was reflected by the severityDuring
of theend-stage
liver disease requiring
study period, 2,728 patients
Futile
Score geliştiriliyor
ay içindeki
hasta kaybı
olarak
belirleniyor)
were admitted to thetreatment
MICU, of whom 152
ICU management
and/or (3
life-support
and by
significant
underlying
comorbidities.
The
data
indicate
that
excellent long-term
2110
Crit Care Med 2010 Vol. 38, No. 11
Futile
outcome % 22 (37/169)
outcome can be achieved for patients with MELD scores of 40 or
more if theyskorda
survive4the
first yearrisk
afterfaktörü
OLT. tespit edilmiştir:
Geliştirilen
bağımsız
LT in highest Acuity Recipients
UCLA Futility risk score = 0,5 x MELD + 5 x (1= Charlson index ≥ 6, = 0, if
Charlson index < 6 + 4 x (1= Cardiac risk, 0 = if no risk) + 3 x (1 = septic shock,
0 = no septic shock
TABLE 4. Independent Risk Factors for Futility and Failure-Free
Survival
Risk Factors for Futility∗
OR
95% CI
Futility score
P
MELD (per point)
1.14
0.98–1.32
0.091
Pre-OLT septic shock
2.38
0.96–5.56
0.059
Cardiac risk
3.14
1.25–7.92
0.015
Age-adjusted Charlson
3.95
1.18–13.2
0.026
Comorbidity Index ≥6
Risk Factors for
HR
95%-CI
P
Failure-Free Survival†
Recipient age (per year)
1.05
1.01–1.10
0.021
Petrowsky, Ann Surg 259, 2014, 1186-1194
Complication
2.23
1.17–4.29
0.015
Titel grade 4‡
Hepatitis
C für Allgemein-, Viszeral2.82
1.40–5.70
0.004
Klinik
und Transplantationschirurgie
Metabolic syndrome
3.81
1.76–8.27
0.001
Skor
low risk
middle risk
high risk
≤ 22
22.5-25.5
≥ 26
Titel
∗
Logistic model (c-statistic 0.754).
†Cox model (Harrells c-statistic 0.720).
‡Postoperative complications grade 4 were defined as life-threatening complications
requiring ICU management for single- (grade 4a) or multiorgan dysfunction (grade 4b).
CI indicates confidence interval; HR, hazard ratio.
⃝
C 2013 Lippincott Williams & Wilkins
ght © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
27/04/16
En Acil Durumlarda KC Transplantasyonu
Petrowsky et al
Titel
Olgu 2
Annals of Surgery ! Volume 259, Number 6, June 2014
Olgu 2
• 
50 yaşında erkek hasta
• 
MELD 28
• 
Primer sklerozan kolanjit (PSK) siroz
• 
Tekrarlayıcı kolanjit geciriyor ( Candida alb ve VRE dahil)
• 
Kliniğe kabul edildiğinde diüretikle kontrol edilemeyen ascitt=> 6 kez
FIGURE 4.tedavisi
Posttransplant
futility. Early postPrometheus
uygulanıyor
• 
4toMRGN
(karbapenem
resistanli
cumulative
futility
riskEnterbactereocea)
score for therektal kolonizasyonlu
transplant patient survival (A) stratified
• 
low- (≤22
points),
intermediate(22.5–25.5
Pnömoni
nedeniyle
1 hafta
mekanik ventilasyon
gerekiyor => iyileşiyor
• 
4(log-rank
aydir Klinikte,
kadar 2 defa
YBÜ tedavisi
görmüş
test,bugünr
P < 0.0001).
Points
were as-
points), and high-risk group (≥26 points)
• 
signed to
eachalındıktan
futility risk
factor
according
Bekleme
listesine
sonra
Üst GIS
Kanaması geçiriyor
• 
Endoskopi girişimi basarili olamiyor/kanamayı engelleyen stent
to the odds ratio. The cumulative futility risk
score is calculated according to the following formula:
score ==>
0.5
× (MELD
score)
+ gerekyior
•  Akut
solunum yetmezliği
3. kere
mekanik
ventilasyon
Titel Charlson Comorbidity Index ≥6;
5 × (1 =
0 = Charlson Comorbidity Index <6) + 4 ×
(1 = cardiac risk; 0 = no cardiac risk) + 3
× (1 = septic shock; 0 = no sepsis). The receiver operating characteristic curve of the
logistic futility risk model had a c-statistic of
0.754 (B). C, The predictive futility risk according to the cumulative futility risk score.
The intercept of this model was −7.9. D, Patients’ survival of the nonfutile and the entire
group.
Olgu 3
• 
45 yaşında hasta
• 
Hasta 1 hafta YBÜde kalıyor, kendi şartlarına göre iyileşiyor
• 
NASH siroz, BMI 27
• 
1 hafta sonra organ temin edilip transplante ediliyor
• 
Diüretik ile kontrol edilemeyen ascitt
• 
YBÜ Tx‘dan sonra 3 gün
• 
Insüline bağımlı Diabetes mellitus
• 
Toplam klinikte kalma süresi> 7 ay
• 
Bili 21,4 mg/dl, SCr 6,9 mg/dl => CVVHD
• 
Tx‘dan 7 hafta sonra klinikten taburcu oluyor
• 
PT: %41, (INR 1,7), aPTT 39,7 sec., fibrinojen 148 mg/dl, PLT 39/nl
• 
MELD: 37
Titel
Titel
FIGURE 5. Posttransplant survival of nonfutile group stratified for independent predictors of graft-failure-free survival. KaplanMeier survival plots illustrate patients’ overall survival for nonfutile group (n=132) with (A) recipient
age of
55 years or less
Yoğun
Bakımcının
KCversus
Naklindeki Rolü
more than 55 years (P = 0.0015), (B) postoperative complications grade 4 versus less than grade 4 (P = 0.142), (C) hepatitis
Olgu 3
Disiplinler
Çalışma
C versus no hepatitis C (P = 0.039), and (D) pretransplant MetS versus no pretransplant MetS (P
= 0.0003).Arası
P values
for curveGerektiriyor
comparison are computed using the log-rank (Mantel-Cox) test. HCV indicates hepatitis C virus; MetS, metabolic syndrome.
Hepatolog/Nefrolog
1192 | www.annalsofsurgery.com
⃝
C 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cerrah
Hasta
Anestezi
Yoğun bakım
Titel
Titel
4
Table 1 Baseline, donor, and outcome characteristics for 198 transplanted critically ill cirrhosis patients (first
objective, five sites) and 106 nontransplanted critically ill cirrhosis patients (second objective, two sites)
First objective (n = 198)
Second objective (n = 106)
Age (years)
53 (10)
54 (9.5)
Female
67 (34%)
31 (29%)
Hepatitis C
62 (31%)
30 (29%)
Hepatitis B
17 (9%)
7 (7%)
Alcohol
PSC/PBC
30 (15%)
30 (15%)
24 (23%)
9 (9%)
NASH/Cryptogenic
17 (9%)
18 (17%)
Etiology
27/04/16
Comorbidities/Cirrhotic complications
Charlson Score
1 (1)
0.7 (1)
Ascites
100 (96%)
61 (71%)
Variceal bleeding
53 (56%)
54 (64%)
Hepatic encephalopathy
Hepatorenal syndrome
107 (94%)
84 (63%)
67 (79%)
71 (69%)
Spontaneous bacterial peritonitis
34 (41%)
37 (44%)
Hemoglobin (g/L)
85 (23)
84 (22)
White blood count (×109/L)
8.9 (5.2-14.5)
9.7 (6.5-15.4)
Platelet count (×109/L)
64 (43-95)
70 (40-118)
Hematology
Biochemistry
ET Bölgesinde 1-yıllık Sağ kalım Oranı (01/2014-12/2014)
Olan Hastaların 2.2 (1.8-3.3)
INRYB Bağlı Transplantasyon
2.1 (1.7-2.8)
ALT (U/L)
46 (25-82)
53 (27-128)
Nakil Sonrası Değerlendirilmesi
Bilirubin (μM)
273 (95-575)
239 (95-469)
Sodium (mM)
137 (130-143)
136 (130-143)
Lactate (mM)
2.8 (1.6-4.6)
3.6 (2.4-7.8)
pH
7.39 (7.32-7.46)
7.36 (7.25-7.44)
Creatinine (μM)
197 (109-308)
207 (122-301)
Physiology
Mean arterial pressure (mm Hg)
Glasgow Coma Scale score (admission)
PO2/FiO2 ratio (mm Hg, admission)
67 (60-83)
52 (10)
10 (5)
Transplant
227 (106)n= 198
9 (5)
non-Transplant
n= 106
195 (112)
Organ support
Vasopressors (admission)
84/186 (45%)
54/85 (64%)
Vasopressors (any day)
95/108 (88%)
58/74 (78%)
Mechanical ventilation (admission)
MV (any day)
76/134 (57%)
100/114 (88%)
50/86 (58%)
61/74 (82%)
RRT (admission)
49/187 (26%)
27/87 (31%)
RRT (any day)
78/139 (56%)
42/76 (55%)
Aggregate scores
Child Turcotte Pugh (listing)
12.4 (1.6)
MELD (listing)
24 (16-36)
23 (15-35)
MELD (admit)
34 (26-39)
36 (27-40)
MELD (transplant)
SOFA (admit)
34 (27-40)
12.5 (4)
14 (4)
SOFA (48 hours)
13 (5)
17 (4)
SOFA (transplant)
14 (4)
Titel
Karvellas, Crit Care 2013, 17, R 28
Titel
p = 0.048
p = 0.001
KC Yetmezliğinde mekanik ventilasyon ve vazopressör tedavisi
gereken hastalar transplant olur mu?
YB Bağlı Transplantasyon Olan Hastaların
Nakil Sonrası Değerlendirilmesi
Transplant ve
ventilasyon
YB ve mekanik
ventilasyon
YB ve nonventilasyon
YB bağlı
olmayan hasta
N=40
N= 80
N = 120
Mekanik ventilasyondaki hastaların transplant‘a kabul edilme koşulları:
FiO2 ≤ 40%, PEEP ≤10 mbar, NE: ≤ 0.1 µg/kg/min, infeksiyon belirtileri meçhul
Titel
Knaak, Liver Transpl., 21, 2015, 761-767
Karvellas, Crit Care 2013, 17, R 28
Titel
Bulgular
Örnek
LIVER TRANSPLANTATION, Vol. 21, No. 6, 2015
KNAAK ET AL. 765
• 
80 yaşında demanslı huzurevinde yaşayan hasta düşüp, femur
boynunu kırıyor
• 
Endoprotez ameliyatta uygulanıyor
• 
Postoperatif dönemde:
•  Pnömoni
•  Sepsis
•  Akut böbrek hasari (AKIN III)
Nasıl karar alınabilir?
Knaak, Liver Transpl., 21, 2015, 761-767
Titel
Titel
5
Figure 1.
(A) Patient survival after transplantation. (B) Graft survival after transplantation.
vasopressors, mechanical ventilation, and the pres-
patients because a similarly high mortality rate was
27/04/16
Karaciğer Naklinde Yoğun Bakımcının Rolü
Olgu 3
Pubmed‘den cıkan sonuç
• 
45 yaşında hasta
• 
NASH siroz, BMI 27
• 
Diüretik ile kontrol edilemeyen asit
• 
İnsülin bağımlı diabetes mellitus
• 
Bil 21,4 mg/dl, SCr 6,9 mg/dl => CVVHD
• 
PT: %41, (INR 1,7), aPTT 39,7 sec., fibrinojen 148 mg/dl, PLT 39/nl
• 
MELD: 37
Titel
Titel
Yoğun Bakım Uzmanının Sağkalım Üzerine Etkisi
Meta-analiz
Yoğun Bakım Uzmanının Sağ kalım Üzerine Etkisi
Meta-analiz
ICU Mortality
Hospital Mortality
Risk ratio
(95% CI)
Study
% Weight
Pollack et al
0.53 (0.17,1.64)
Brown et al
0.48 (0.32,0.72)
8.4
Kuo et al
0.60 (0.49,0.73)
11.3
Al-Asadi et al
0.82 (0.61,1.10)
9.9
Manthous et al
0.71 (0.54,0.94)
10.1
Marini et al
0.54 (0.26,1.10)
4.7
DiCosmo et al
0.59 (0.44,0.79)
10.0
Ghorra et al
0.42 (0.20,0.90)
4.4
Baldock et al
0.69 (0.52,0.91)
10.0
Rosenfeld et al
0.15 (0.05,0.50)
2.3
Goh et al
0.38 (0.27,0.53)
9.3
Reich et al
0.61 (0.41,0.92)
8.2
Topeli et al
1.44 (1.00,2.07)
8.9
Overall (95% CI)
0.61 (0.50,0.75)
.1
1
2.5
% Weight
Li
0.93 (0.78,1.13)
11.0
Reynolds, et al
0.77 (0.63,0.94)
10.8
Brown, et al
0.69 (0.52,0.93)
Multz et al retrospective
0.81 (0.62,1.07)
Multz et al prospective
0.74 (0.53,1.05)
7.5
Manthous et al
0.72 (0.59,0.89)
10.6
Carson et al
1.39 (0.91,2.11)
6.2
Hanson et al
0.67 (0.19,2.29)
1.2
Pronovost et al
0.58 (0.43,0.79)
8.3
Dimick et al
0.26 (0.12,0.59)
2.5
Dimick et al
0.19 (0.07,0.55)
1.6
Baldock et al
0.65 (0.51,0.83)
Rosenfeld et al
0.39 (0.19,0.81)
2.9
Blunt et al
0.69 (0.54,0.87)
10.0
Overall (95% CI)
0.71 (0.62,0.82)
8.6
9.0
9.7
10
Risk ratio
.1
Titel
Risk ratio
(95% CI)
Study
Pronovost, JAMA: 288: 2151-2162
Titel
1
Risk ratio
10
Pronovost, JAMA: 288: 2151-2162
6

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