Successful implementation of an Enhanced Recovery After Surgery program shortens length of stay and improves postoperative pain, and bowel and bladder function after colorectal surgery.

BACKGROUND: Despite international data indicating that Enhanced Recovery After Surgery (ERAS) programs, which combine evidence-based perioperative strategies, expedite recovery after surgery, few centers have successfully adopted this approach within the U.S. We describe the implementation and efficacy of an ERAS program for colorectal abdominal surgery in a tertiary teaching center in the U.S. METHODS: We used a multi-modal and continuously evolving approach to implement an ERAS program among all patients undergoing colorectal abdominal surgery at a single hospital at the University of California, San Francisco. 279 patients who participated in the Enhanced Recovery after Surgery program were compared to 245 previous patients who underwent surgery prior to implementation of the program. Primary end points were length of stay and readmission rates. Secondary end points included postoperative pain scores, opioid consumption, postoperative nausea and vomiting, length of urinary catheterization, and time to first solid meal. RESULTS: ERAS decreased both median total hospital length of stay (6.4 to 4.4 days) and post-procedure length of stay (6.0 to 4.1 days). 30-day all-cause readmission rates decreased from 21 to 9.4 %. Pain scores improved on postoperative day 0 (3.2 to 2.1) and day 1 (3.2 to 2.6) despite decreased opioid. Median time to first solid meal decreased from 4.7 to 2.7 days and duration of urinary catheterization decreased from 74 to 46 h. Similar improvements were observed in all other secondary end points. CONCLUSIONS: These results confirm that a multidisciplinary, iterative, team-based approach is associated with a reduction in hospital stay and an acceleration in recovery without increasing readmission rates.

Discrete change in volatile anesthetic sensitivity in mice with inactivated tandem pore potassium ion channel TRESK.

BACKGROUND: We investigated the role of tandem pore potassium ion channel (K2P) TRESK in neurobehavioral function and volatile anesthetic sensitivity in genetically modified mice. METHODS: Exon III of the mouse TRESK gene locus was deleted by homologous recombination using a targeting vector. The genotype of bred mice (wild type, knockout, or heterozygote) was determined using polymerase chain reaction. Morphologic and behavioral evaluations of TRESK knockout mice were compared with wild-type littermates. Sensitivity of bred mice to isoflurane, halothane, sevoflurane, and desflurane were studied by determining the minimum alveolar concentration preventing movement to tail clamping in 50% of each genotype. RESULTS: With the exception of decreased number of inactive periods and increased thermal pain sensitivity (20% decrease in latency with hot plate test), TRESK knockout mice had healthy development and behavior. TRESK knockout mice showed a statistically significant 8% increase in isoflurane minimum alveolar concentration compared with wild-type littermates. Sensitivity to other volatile anesthetics was not significantly different. Spontaneous mortality of TRESK knockout mice after initial anesthesia testing was nearly threefold higher than that of wild-type littermates. CONCLUSIONS: TRESK alone is not critical for baseline central nervous system function but may contribute to the action of volatile anesthetics. The inhomogeneous change in anesthetic sensitivity corroborates findings in other K2P knockout mice and supports the theory that the mechanism of volatile anesthetic action involves multiple targets. Although it was not shown in this study, a compensatory effect by other K2P channels may also contribute to these observations.

Knockout of the gene encoding the K(2P) channel KCNK7 does not alter volatile anesthetic sensitivity.

The molecular site of action for volatile anesthetics remains unknown despite many years of study. Members of the K(2P) potassium channel family, whose currents are potentiated by volatile anesthetics have emerged as possible anesthetic targets. In fact, a mouse model in which the gene for TREK-1 (KCNK2) has been inactivated shows resistance to volatile anesthetics. In this study we tested whether inactivation of another member of this ion channel family, KCNK7, in a knockout mouse displayed altered sensitivity to the anesthetizing effect of volatile anesthetics. KCNK7 knockout mice were produced by standard gene inactivation methods. Heterozygous breeding pairs produced animals that were homozygous, heterozygous or wild-type for the inactivated gene. Knockout animals were tested for movement in response to noxious stimulus (tail clamp) under varying concentrations of isoflurane, halothane, and desflurane to define the minimum alveolar concentration (MAC) preventing movement. Mice homozygous for inactivated KCNK7 were viable and indistinguishable in weight, general development and behavior from heterozygotes or wild-type littermates. Knockout mice (KCNK7-/-) displayed no difference in MAC for the three volatile anesthetics compared to heterozygous (+/-) or wild-type (+/+) littermates. Because inactivation of KCNK7 does not alter MAC, KCNK7 may play only a minor role in normal CNS function or may have had its function compensated for by other inhibitory mechanisms. Additional studies with transgenic animals will help define the overall role of the K(2P) channels in normal neurophysiology and in volatile anesthetic mechanisms.

The ventilatory stimulant doxapram inhibits TASK tandem pore (K2P) potassium channel function but does not affect minimum alveolar anesthetic concentration.

TWIK-related acid-sensitive K(+)-1 (TASK-1 [KCNK3]) and TASK-3 (KCNK9) are tandem pore (K(2P)) potassium (K) channel subunits expressed in carotid bodies and the brainstem. Acidic pH values and hypoxia inhibit TASK-1 and TASK-3 channel function, and halothane enhances this function. These channels have putative roles in ventilatory regulation and volatile anesthetic mechanisms. Doxapram stimulates ventilation through an effect on carotid bodies, and we hypothesized that stimulation might result from inhibition of TASK-1 or TASK-3 K channel function. To address this, we expressed TASK-1, TASK-3, TASK-1/TASK-3 heterodimeric, and TASK-1/TASK-3 chimeric K channels in Xenopus oocytes and studied the effects of doxapram on their function. Doxapram inhibited TASK-1 (half-maximal effective concentration [EC50], 410 nM), TASK-3 (EC50, 37 microM), and TASK-1/TASK-3 heterodimeric channel function (EC50, 9 microM). Chimera studies suggested that the carboxy terminus of TASK-1 is important for doxapram inhibition. Other K2P channels required significantly larger concentrations for inhibition. To test the role of TASK-1 and TASK-3 in halothane-induced immobility, the minimum alveolar anesthetic concentration for halothane was determined and found unchanged in rats receiving doxapram by IV infusion. Our data indicate that TASK-1 and TASK-3 do not play a role in mediating the immobility produced by halothane, although they are plausible molecular targets for the ventilatory effects of doxapram.

Chirality in anesthesia II: stereoselective modulation of ion channel function by secondary alcohol enantiomers.

Chirality has been proposed as a means for distinguishing relevant from irrelevant molecular targets of action, but the sensitivity and specificity of this test is unknown for volatile anesthetics. We applied enantiomers of two chiral anesthetic alcohols (2-butanol and 2-pentanol) that are enantioselective for the minimum alveolar concentration (MAC) preventing movement in 50% of animals and one (2-hexanol) that was not to frog oocytes. Each oocyte expressed one of three anesthetic-sensitive ion channels: a Twik-related-spinal cord K+ (TRESK) channel, a gamma-amino butyric acid type A (GABA(A)) receptor and an N-methyl-d-aspartate (NMDA) receptor. Using voltage-clamp techniques, we found that 2-butanol was not enantioselective for any channel (e.g., 16 mM 2-butanol R(-) and S(-) enantiomers decreased current through an NMDA receptors by 44% +/- 3% [mean +/- se] and 37% +/- 4%, respectively); 2-pentanol was enantioselective for one channel (the GABA(A) receptor, the enantiomers increasing current by 277% +/- 20% and 141% +/- 30%); 2-hexanol was enantioselective for both GABA(A) and NMDA receptors (e.g., decreasing current through the NMDA receptor by 19% +/- 3% and 43% +/- 5%). We calculated the sensitivity and specificity of chirality as a test of anesthetic relevance under two scenarios: 1) all three channels were relevant mediators of MAC and 2) no channel was a mediator of MAC. These sensitivities and specificities were poor because there is no consistent correspondence between receptor and whole animal results. We recommend that enantioselectivity not be used as a test of relevance for inhaled anesthetic targets.

Protective effects of TASK-3 (KCNK9) and related 2P K channels during cellular stress.

Tandem pore domain (or 2P) K channels form a recently isolated family of channels that are responsible for background K currents in excitable tissues. Previous studies have indicated that 2P K channel activity produces membrane hyperpolarization, which may offer protection from cellular insults. To study the effect of these channels in neuroprotection, we overexpressed pH-sensitive 2P K channels by transfecting the partially transformed C8 cell line with these channels. Tandem pore weak inward rectifier K channel (TWIK)-related acid-sensitive K channel 3 (TASK-3, KCNK9) as well as other pH sensitive 2P K channels (TASK-1 and TASK-2) enhanced cell viability by inhibiting the activation of intracellular apoptosis pathways. To explore the cellular basis for this protection in a more complex cellular environment, we infected cultured hippocampal slices with Sindbis virus constructs containing the coding sequences of these channels. Expression of TASK-3 throughout the hippocampal structure afforded neurons within the dentate and CA1 regions significant protection from an oxygen-glucose deprivation (OGD) injury. Neuroprotection within TASK-3 expressing slices was also enhanced by incubation with isoflurane. These results confirm a protective physiologic capability of TASK-3 and related 2P K channels, and suggest agents that enhance their activity, such as volatile anesthetics may intensify these protective effects.

Two-pore domain potassium channels: new sites of local anesthetic action and toxicity.

Potassium (K+) channels form the largest family of ion channels with more than 70 such genes identified in the human genome. They are organized in 3 superfamilies according to their predicted membrane topology: (1) subunits with 6 membrane-spanning segments and 1-pore domain, (2) subunits with 2 membrane-spanning segments and 1-pore domain, and (3) subunits with 4 membrane-spanning segments and 2-pore domains arrayed in a tandem position. The last family has most recently been identified and comprises the so-called 2-pore domain potassium (K2P) channels, believed responsible for background or leak K+ currents. Despite their recent discovery, interest in them is growing rapidly with more than 270 references in the literature reported (www.ipmc.cnrs.fr/~duprat/2p/ref2p.htm#2P, accessed October 30, 2004). K2P channels are widely expressed in the central nervous system and are involved in the control of the resting membrane potential and the firing pattern of excitable cells. This article will therefore review recent findings on actions of local anesthetics with respect to 2P channels. It begins with an overview of the role of background K+ channels in neuronal excitability and nerve conduction and is followed by a description of the K2P channel family including experimental evidence for the contribution of K2P channels to the mechanism of action and toxicity of local anesthetics.

Update on tandem pore (2P) domain K+ channels.

The volatile anesthetics are widely used in clinical practice today to produce a state of general anesthesia. But despite more than 150 years of use and substantial scientific investigation, the mechanism by which they produce central nervous system depression remains elusive. Complete understanding of the cellular and molecular basis of the anesthetized state produced by volatile anesthetics most likely involves modulation of the activity of ion channel proteins; these macromolecules provide the most likely molecular targets for these agents. Many studies suggest the involvement of GABAergic and glutamatergic receptor systems in mediating the action of volatile anesthetics. Another ionic current found ubiquitously in neuronal tissues, background potassium currents (also known as resting or leak K+ currents), have recently emerged as plausible targets for volatile anesthetics. A unique structural class of K+ channels with two pore-forming sequences in tandem (2P K+ channels) contributes significantly to background K+ currents. The complete identification of all the 2P K+ channel family members has likely been accomplished. Within intact neuronal systems, background K+ channels are responsible for essential inhibition; these actions are enhanced by volatile anesthetics. Thus, members of this family have emerged as strong candidates for the molecular site of volatile anesthetic action.

Identification of native rat cerebellar granule cell currents due to background K channel KCNK5 (TASK-2).

The TWIK-related, Acid Sensing K (TASK-2; KCNK5) potassium channel is a member of the tandem pore (2P) family of potassium channels and mediates an alkaline pH-activated, acid pH-inhibited, outward-rectified potassium conductance. In previous work, we demonstrated TASK-2 protein expression in newborn rat cerebellar granule neurons (CGNs). In this study, we demonstrate TASK-2 functional expression in CGNs as a component of the pH-sensitive, volatile anesthetic-potentiated, standing-outward potassium conductance (I(K,SO)). Using excised, inside-out patch-clamp technique, we studied CGNs grown in primary culture. We identified four distinct, noninactivating single channel potassium conductances, Types 1-4. Types 1-3 have previously been attributed to TASK-1 (KCNK3), TASK-3 (KCNK9) and TASK-1/TASK-3 heteromers, and TREK-2 (KCNK10) 2P potassium channel function, respectively; however, the Type 4 conductance is currently unassigned. Previous studies demonstrated that Type 4 single channel activity is potentiated by extracellular, alkaline pH and cytoplasmic arachidonic acid (10-20 microM) and inhibited by cytoplasmic tetraethylammonium (TEA; 1 mM). We determined that heterologously expressed TASK-2 channels have single channel gating, conductance properties and pH sensitivity identical to the Type 4 conductance. Additionally, we found that TASK-2 single channel activity, like the Type 4 conductance is potentiated by cytoplasmic arachidonic acid (20 microM) and inhibited by cytoplasmic TEA (1 mM). We conclude that TASK-2 mediates the Type 4 single channel conductance in CGNs as a component of I(K,SO).

Localization of the tandem pore domain K+ channel KCNK5 (TASK-2) in the rat central nervous system.

Tandem pore domain K+ channels (2P K+ channels) are responsible for background K+ currents. 2P K+ channels are the most numerous encoded K+ channels in the Caenorhabditis elegans and Drosophila melanogaster genomes and to date 14 human 2P K+ channels have been identified. The 2P K+ channel TASK-2 (also named KCNK5) is sensitive to changes in extracellular pH, inhibited by local anesthetics and activated by volatile anesthetics. While TASK-1 has been shown to be involved in controlling neuronal cell excitability, much less is known about the cellular expression and function of TASK-2, originally cloned from human kidney. Previous studies demonstrated TASK-2 mRNA expression in high abundance in human kidney, liver, and pancreas, but only low expression in mouse brain or even absent expression in human brain was reported. In this study we have used immunohistochemical methods to localize TASK-2 at the cellular level in the rat central nervous system. TASK-2 immunoreactivity is prominently found in the rat hippocampal formation with the strongest staining observed in the pyramidal cell layer and in the dentate gyrus, and the Purkinje and granule cells of cerebellum. Additional immunofluorescence studies in cultured cerebellar granule cells demonstrate TASK-2 localization to the neuronal soma and to the proximal regions of neurites of cerebellar granule cells. The superficial layers of spinal cord and small-diameter neurons of dorsal root ganglia also showed strong TASK-2 immunoreactivity. These results suggest a possible involvement of TASK-2 in central mechanisms for controlling cell excitability and in peripheral signal transduction.

Isobolographic analysis of non-depolarising muscle relaxant interactions at their receptor site.

Administration of certain combinations of non-depolarising muscle relaxants produces greater than expected neuromuscular blockade. Synergistic effects may be explained by drug interactions with the postsynaptic muscle nicotinic acetylcholine receptor. To investigate this hypothesis, the adult mouse muscle nicotinic acetylcholine receptor (alpha(2)beta delta epsilon) was heterologously expressed in Xenopus laevis oocytes and activated by the application of acetylcholine (10 microM). The effects of five individually applied muscle relaxants and six combinations of structurally similar and dissimilar compounds were studied. Drug combinations containing equipotent concentrations of two agents were tested and dose-response curves were determined. All compounds tested alone and in combination produced rapid and readily reversible, concentration-dependent inhibition. Isobolographic and fractional analyses indicated additive interactions for all six tested combinations. These findings suggest that synergistic neuromuscular blocking effects, observed for the administration of certain combinations of muscle relaxants, do not result from purely postsynaptic binding events at the muscle nicotinic acetylcholine receptor, but rather from differential actions on pre- and postsynaptic sites.

Anaphylaxis complicating graft reperfusion during orthotopic liver transplantation: a case report.

Hemodynamic instability may occur during liver transplantation especially following unclamping the portal vein. A period of hypotension (postreperfusion syndrome) is usually responsive to treatment with fluids, calcium, sodium bicarbonate, and vasoactive drugs, but if hypotension persists, other causes must be sought out. In this report, we present a case in which anaphylaxis, most likely due to a component of the University of Wisconsin preservation solution, occurred coincident with liver reperfusion and severely exacerbated reperfusion hemodynamic instability. To our knowledge, this is the first report of anaphylaxis at the time of reperfusion and may provide an explanation for cases of vasoplegic syndrome associated with graft reperfusion.

Molecular biology of background K channels: insights from K(2P) knockout mice.

K(2P) channels are a family of cellular proteins that are essential for electrical signaling throughout the body. There are six K(2P) channel subfamilies, consisting of 15 distinct mammalian genes. K(2P) channels display a remarkable range of regulation by cellular, physical and pharmacologic agents, including protein kinases, intracellular Ca(2+), changes in internal and external pH, anesthetic agents, heat, stretch and membrane deformers. The molecular and cellular mechanisms underlying this regulation are complex and cooperate at many different levels. Recent research has provided strong evidence that the spatiotemporal-specific expression of K(2P) channels are determinants of physiologic selectivity and specificity. In recent years, knockout mice have been generated with inactivated K(2P) channel genes. These animals shed new light on the contribution of K(2P) channels to normal and abnormal physiology. In this review, we summarize the published data on these mice to broaden the understanding of the role of K(2P) channel activity.

Regional expression of the anesthetic-activated potassium channel TRESK in the rat nervous system.

The two-pore-domain potassium (K(2P)) channels contribute to background (leak) potassium currents maintaining the resting membrane potential to play an important role in regulating neuronal excitability. As such they may contribute to nociception and the mechanism of action of volatile anesthetics. In the present study, we examined the protein expression pattern of the K(2P) channel TRESK in the rat central nervous system (CNS) and peripheral nervous system (PNS) by immunohistochemistry. The regional distribution expression pattern of TRESK has both similarities and significant differences from that of other K(2P) channels expressed in the CNS. TRESK expression is broadly found in the brain, spinal cord and dorsal root ganglia (DRG). TRESK expression is highest in important CNS structures, such as specific cortical layers, periaqueductal gray (PAG), granule cell layer of the cerebellum, and dorsal horn of the spinal cord. TRESK expression is also high in small and medium sized DRG neurons. These results provide an anatomic basis for identifying functional roles of TRESK in the rat nervous system.

A new look at the respiratory stimulant doxapram.

A number of life-threatening clinical disorders may be amenable to treatment with a drug that can stimulate respiratory drive. These include acute respiratory failure secondary to chronic obstructive pulmonary disease, post-anesthetic respiratory depression, and apnea of prematurity. Doxapram has been available for over forty years for the treatment of these conditions and it has a low side effect profile compared to other available agents. Generally though, the use of doxapram has been limited to these clinical niches involving patients in the intensive care, post-anesthesia care and neonatal intensive care units. Recent basic science studies have made considerable progress in understanding the molecular mechanism of doxapram's respiratory stimulant action. Although it is unlikely that doxapram will undergo a clinical renaissance based on this new understanding, it represents a significant advance in our knowledge of the control of breathing.

Antiemetics of the 5-hydroxytryptamine 3A antagonist class inhibit muscle nicotinic acetylcholine receptors.

Antagonists of the serotonergic 5-hydroxytryptamine 3A receptor (5-HT(3A)R) and muscle nicotinic acetylcholine receptors (nAChR) are widely used in anesthesia practice. Both 5-HT(3A)R and nAChR are ligand-gated ion channels with known pharmacological overlap between some of their agonists and antagonists. We studied the actions of clinically used 5-HT(3A)R antagonist antiemetics and nondepolarizing muscle blockers on ionic currents elicited by the activation of mammalian 5-HT(3A)R and muscle nAChR, expressed in Xenopus laevis oocytes. Currents were recorded using a whole-cell two-electrode voltage clamp technique. Dolasetron, ondansetron, and granisetron reversibly inhibited 5-HT(3A)R function at nanomolar concentrations with 50% inhibitory concentrations (IC(50)) of 11.8, 6.4, and 0.2 nM; the rank order of inhibition correlated well with their clinical antiemetic potencies. The principal metabolite of dolasetron, hydrodolasetron, was 40 times more potent than the parent compound on 5-HT(3A)R (IC(50) = 0.29 nM). The potency of the nondepolarizing muscle blocker d-tubocurarine in blocking 5-HT(3A)R was similar to that of the antiemetics and significantly more than vecuronium and rapacuronium (IC(50) = 11.4 nM, 18.9 microM, 60.5 microM). Conversely, ondansetron, dolasetron, and granisetron also reversibly inhibited nAChR currents in a dose-dependent manner with IC(50)s of 14.2, 7.8, and 4.4 microM for the adult nAChR and 16.0, 18.6, and 13.9 microM for the embryonic nAChR. Again, hydrodolasetron showed significantly (10 times) more inhibitory potency on the adult nAChR than the parent compound dolasetron. These results indicate that drugs that target specific ligand-gated ion channels may also affect other ion channel types.

Species-specific differences in response to anesthetics and other modulators by the K2P channel TRESK.

UNLABELLED: TRESK (TWIK-related spinal cord K+ channel) is the most recently characterized member of the tandem-pore domain potassium channel (K2P) family. Human TRESK is potently activated by halothane, isoflurane, sevoflurane, and desflurane, making it the most sensitive volatile anesthetic-activated K2P channel yet described. Herein, we compare the anesthetic sensitivity and pharmacologic modulation of rodent versions of TRESK to their human orthologue. Currents passed by mouse and rat TRESK were enhanced by isoflurane at clinical concentrations but with significantly lower efficacy than human TRESK. Unlike human TRESK, the rodent TRESKs are strongly inhibited by acidic extracellular pH in the physiologic range. Zinc inhibited currents passed by both rodent TRESK in the low micromolar range but was without effect on human TRESK. Enantiomers of isoflurane that have stereoselective anesthetic potency in vivo produced stereospecific enhancement of the rodent TRESKs in vitro. Amide local anesthetics inhibited the rodent TRESKs at almost 10-fold smaller concentrations than that which inhibit human TRESK. These results identified interspecies differences and similarities in the pharmacology of TRESK. Further characterization of TRESK expression patterns is needed to understand their role in anesthetic mechanisms. IMPLICATIONS: Mouse and rat TRESK (TWIK-related spinal cord K+ channel) have different pharmacologic responses compared with human TRESK. In particular, we found stereospecific differences in response to isoflurane by the rodent TRESKs but not by human TRESK. TRESK may be a target site for the mechanism of action of volatile anesthetics.

Functional inhibition by methadone of N-methyl-D-aspartate receptors expressed in Xenopus oocytes: stereospecific and subunit effects.

UNLABELLED: Methadone is a strong opioid analgesic that is finding increasing use in chronic pain therapeutics. We explored its reported efficacy for inhibiting N-methyl-D-aspartate (NMDA) receptors in a functional electrophysiologic assay (Xenopus laevis oocyte expression). Racemic methadone inhibited all subtypes of rat NMDA receptors with derived 50% inhibitory concentrations in the low micromolar range. These concentrations overlap with clinically achievable concentrations reported in pharmacokinetic studies. In contrast, morphine inhibited these functional ion channels only at 8-16 times larger concentrations. The NR1/2A and NR1/2B subtype combinations were in general significantly more sensitive to inhibition by methadone and morphine compared with the NR1/2C and NR1/2D subtypes. In the presence of racemic methadone, the maximum NMDA-stimulated currents were markedly decreased, but the NMDA concentration producing 50% of maximal activation was altered only slightly, indicating that methadone blocks by a noncompetitive mechanism. Although stereoisomers of methadone showed minimal stereoselectivity in most subtypes, R(-) methadone was highly selective in its inhibition of the NR1/2A combination. These results provide further functional data describing the NMDA receptor inhibitory actions of methadone and support the hypothesis that methadone acts through both opioid and NMDA receptor mechanisms. IMPLICATIONS: At clinically achievable concentrations, methadone inhibits functional N-methyl-D-aspartate receptors. These results indicate a unique mode of action by this opioid that may enhance its ability to treat chronic pain and to limit opioid tolerance.

Evaluation of the splanchnic circulation with indocyanine green pharmacokinetics in liver transplant patients.

Although indocyanine green (ICG) can be used to estimate cardiac output (CO) and blood volume independently, a recirculatory multicompartmental ICG model enables description of these and additional intravascular factors. This model was used to describe the effect of end-stage liver disease (ESLD) on systemic and splanchnic hemodynamics in patients undergoing orthotopic liver transplantation. ICG disposition was determined during the dissection phase in six patients with ESLD undergoing orthotopic liver transplantation and six healthy adult living liver donors. After injecting ICG, plasma concentrations were obtained for approximately 10 to 12 minutes by noninvasive pulse dye densitometry. The recirculatory model characterizes three distinct intravascular circuits: lumped parallel fast (presumably nonsplanchnic circulation) and slow peripheral (splanchnic) circuits and a central circuit (central blood volume). Mean transit time (MTT) in the fast peripheral circuit was not different in patients with ESLD and controls. However, ESLD resulted in a significant decrease in MTT in the central (0.11 +/- 0.028 [SD] v 0.24 +/- 0.094 minutes in controls; P <.001) and slow peripheral circuit (0.67 +/- 0.41 v 1.37 +/- 0.37 minutes in controls; P <.001) because of increased flows to the central and slow peripheral circuits. These findings are consistent with the described hyperdynamic systemic and splanchnic circulations in patients with ESLD. In conclusion, the ICG model is able to derive estimates of not only blood volume and CO, but also splanchnic hemodynamics under different physiological conditions. This model can be a useful tool to evaluate the effect of pharmacological manipulation of splanchnic hemodynamics.