The effects of plasmalyte-148 vs. Hartmann's solution during major liver resection: a multicentre, double-blind, randomized controlled trial.

BACKGROUND: The acid-base, biochemical and hematological effects of crystalloid solutions have not been comprehensively evaluated in patients with liver resection. DESIGN: multicenter, prospective, double-blind randomized controlled trial investigating the biochemical effects of Hartmann's solution (HS) or Plasmalyte-148 (PL) in 60 patients undergoing major liver resection. PRIMARY OUTCOME: base excess immediately after surgery. SECONDARY OUTCOMES: changes in blood biochemistry and hematology. RESULTS: At completion of surgery, patients receiving HS had equivalent mean standard base excess (-1.7±2.2 vs. -0.9±2.3 meq/L; P=0.17) to those treated with PL. However, patients treated with HS were more hyperchloremic (difference 1.7 mmol/L, 95% CI: 0.2 to 3.2, P=0.03) and hyperlactatemic (difference 0.8 mmol/L, 95% CI: 0.2 to 1.3; P=0.01). In contrast, patients receiving PL had higher mean plasma magnesium levels and lower ionized calcium levels. There were no significant differences in pH, bicarbonate, albumin and phosphate levels. Immediately after surgery, mean PT and aPTT were significantly lower in the PL group. Intraoperatively, the median (IQR) blood loss in the PL group was 300 mL (200:413) vs. 500 mL (300:638) in the HS group (P=0.03). Correspondingly, the postoperative hemoglobin was higher in the PL group. Total complications were more frequent in the HS Group (56% vs. 20%, relative risk 2.8; 95% CI: 1.3 to 6.1; P=0.007). CONCLUSION: In liver resection patients, HS and PL led to similar base excess values but different post operative plasma biochemistry and hematology values. Understanding of these effects may help clinicians individualize fluid therapy in these patients.

Markers of coagulation activation after hepatic resection for cancer: evidence of sustained upregulation of coagulation.

We investigated the possibility that despite postoperative derangements of routine laboratory coagulation tests, markers of coagulation activation and thrombin generation would be normal or increased in patients undergoing hepatic resection for cancer In addition to the conventional coagulation tests prothrombin time and activated partial thromboplastin time, we measured select markers of coagulation activation prothrombin fragments 1 and 2 (PF1 + 2), thrombin-antithrombin complexes and plasma von Willebrand Factor antigen in 21 patients undergoing hepatic resection. The impact of hepatic resection on coagulation and fibrinolysis was studied with thromboelastography. Preoperatively, routine laboratory coagulation and liver function tests were normal in all patients. On the first postoperative day, prothrombin time was prolonged (range 16 to 22 seconds) in eight patients (38%). For these patients, thromboelastography was normal in six (75%), PF1 + 2 was elevated in four (50%), and thrombin-antithrombin complexes and von Willebrand Factor antigen were elevated in all, which was evidence of acute phase reaction, sustained coagulation factor turnover and activation. By the fifth postoperative day, despite normalisation of prothrombin time, markers of increased coagulation activity remained greater than 85% of baseline values. The findings indicate that in patients undergoing liver resection for cancer, there is significant and prolonged postoperative activation of the haemostatic system despite routine coagulation tests being normal or even prolonged. Before considering therapeutic interventions an integrated approach to interpreting haematological data with clinical correlation is essential.

Interpleural analgesia for attenuation of postoperative pain after hepatic resection.

SUMMARY: We performed a prospective randomised trial to evaluate the analgesic efficacy of interpleural analgesia in patients undergoing hepatic resection. The control group (n = 25) received multimodal analgesia with intravenous morphine patient-controlled analgesia; in addition, the interventional group (n = 25) received interpleural analgesia with a 20-ml loading dose of levo bupivacaine 0.5% followed by a continuous infusion of levobupivacaine 0.125%. Outcome measures included pain intensity on movement using a visual analogue scale over 24 h, cumulative morphine and rescue analgesia requirements, patient satisfaction, hospital stay and all adverse events. Patients in the interpleural group were less sedated and none required treatment for respiratory depression compared to 6 (24%) in the control group (p< 0.01). Patients in the interpleural group also had lower pain scores during movement in the first 24 h. Patients' satisfaction, opioid requirements and duration of hospital stay were similar. We conclude that continuous interpleural analgesia augments intravenous morphine analgesia, decreases postoperative sedation and reduces respiratory depression after hepatic resection.

Postoperative changes in prothrombin time following hepatic resection: implications for perioperative analgesia.

Disorders of coagulation may occur after uncomplicated hepatic resection in patients who have normal preoperative coagulation profiles and liver function tests. We present a retrospective study performed in a tertiary care university teaching hospital examining changes in liver function tests and coagulation profiles in patients undergoing hepatic resection. Data were obtained for 124 patients. When compared to the preoperative values, prothrombin times were significantly increased throughout the postoperative period. Prolongation of the prothrombin time was related to both duration of surgery and hepatic resection weight. There was no relationship between prothrombin time and patient age. Disorders of coagulation occur after hepatic resection even in patients who have normal preoperative coagulation and liver function tests. This has implications for anaesthetic practice, particularly when considering the use of an indwelling epidural catheter in patients undergoing hepatic resection.

Peripartum management of a patient with dopamine beta-hydroxylase deficiency, a rare congenital cause of dysautonomia.

We present the first reported case involving the peripartum anaesthetic management of dopamine beta-hydroxylase deficiency in a 22-year-old primigravida with high-grade placenta praevia. Elective caesarean section was performed at 36 weeks gestation with a combined spinal-epidural regional anaesthetic technique. Extensive preparation was undertaken to manage the consequences of obstetric haemorrhage and consideration given to potential pharmacological sensitivities suspected to exist in patients with this rare disorder affecting sympathetic nervous system function. An uncomplicated caesarean section was performed from which the patient recovered well to be discharged home with a healthy baby.