Identification of predictors of death helps in the identification of patients who could benefit from more-aggressive therapeutic strategies. Initiation of therapy at the stage of possible infection improves outcome, and this finding calls for the development of efficient preemptive strategies to fill the gap between empirical and directed therapy.

Purpose: To identify preoperative factors associated with high blood losses during liver transplantation for chronic end-stage liver disease.Methods: Four hundred and ten consecutive patients were included in this retrospective study. Blood losses were calculated, based on transfusion requirements. The population was divided into two groups: the upper quartile was defined as the high blood loss (HBL) group and the lower three quartiles as the low blood loss group. Fourteen preoperative variables were collected. Qualitative variables consisted of the type of hepatopathy, Child-Pugh's classification, sex, the surgical team's experience, previous abdominal surgery and portal hypertension. Quantitative variables were age, hemoglobin concentration Hb, platelet count, prothrombin time, activated partial thromboplastin time, fibrinogen concentration, fibrin degradation products (FDP) and euglobulin lysis time. Univariate analysis and stepwise multivariate analysis were conducted.Results: Patients in the HBL group required 12 units of red blood cell or more to maintain a Hb $100g·L -1 . HBL was associated with severe liver disease, previous abdominal surgery, use of a venovenous bypass and little surgical experience in orthotopic liver transplantation (OLT). In the HBL group several hemostatic parameters were more disturbed before surgery. The multivariate analysis disclosed three independent variables associated with HBL: Hb and FDP concentrations and previous upper abdominal surgery. When combined, these resulted in a high specificity (98%) but low sensitivity to predict blood loss.Conclusion: Despite our efforts we were unable to identify predictive risk factors of bleeding during OLT even in a homogeneous population. Centres should evaluate their practice individually in an attempt to identify patients at high risk of being transfused.

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The release of toxic oxidative free radicals induced by ischemia and reperfusion may jeopardize liver graft function. N-acetylcysteine (NAC) has shown protective effects on hypothermic and warm ischemia reperfusion liver injury in animals. NAC improves hemodynamics and survival rates in patients with fulminant hepatic failure. The aim of this study was to investigate whether intraoperative treatment with NAC would improve hemodynamics and postoperative graft function in liver transplantation. Sixty patients with chronic endstage liver disease were included in a prospective randomized placebo-controlled study. NAC or the same volume of 5% glucose was started during the anhepatic phase. Hemodynamic data and calculated tissue oxygenation parameters were compared throughout the procedure. Postoperative graft function was assessed by measurements of aminotransferases, prothrombin time, and monoethylglycinexylidide test over the 3 first postoperative days. Patient demographics were similar before the infusion of NAC or glucose. Hemodynamic parameters, oxygen consumption, oxygen delivery, oxygen extraction ratio, and lactates were not different throughout the procedure. One hour after the revascularization of the hepatic artery, the oxygen extraction ratio by the liver was similar (17% ؎ 7.6% v 17% ؎ 6.2%) in both groups. Postoperative graft function was comparable within the 3 first postoperative days. This study failed to show any beneficial effect of the intraoperative administration of NAC on hemodynamics and graft function in liver transplantation in patients with chronic liver disease.

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