Comparison Between 2 Strategies of Fluid Management on Blood Loss and Transfusion Requirements During Liver Transplantation.

OBJECTIVE: To compare the effects of low central venous pressure (LCVP) and transesophageal Doppler (TED)-guided fluid management on blood loss and blood transfusion during liver transplantation (LTx). DESIGN: Retrospective study. SETTING: Single institution, university hospital. PARTICIPANTS: Adult recipients of LTx. INTERVENTIONS: Two groups: control (LCVP G), n=45 with CVP maintained 40% lower than the preoperative value during the preanhepatic phase. The mean arterial pressure was kept >60 mmHg. This group was matched with the second group (TED G); n = 45, in which a TED protocol was followed maintaining the systemic vascular resistance (SVR) more than 750 dynes•s•cm-5. Coagulation defects were corrected following thromboelastometry. MEASUREMENTS AND MAIN RESULTS: Intraoperative blood loss, blood products, perioperative creatinine, lactate, and postoperative patients' stratification according to the Acute Kidney Injury Network classification were compared. Prior to the anhepatic phase, CVP was significantly lower in LCVP G (p < 0.001). TED G tended to have less but nonsignificant, blood loss, packed red blood cells, fresh frozen plasma, and platelets and received significantly less colloid and higher norepinephrine. Lactate was significantly higher in LCVP G at the end of the anhepatic phase and end of surgery while urine output in the preanhepatic phase was significantly lower. Creatinine was significantly lower on postoperative days 1 and 3, and Acute Kidney Injury Network stages were better on postoperative day 1 in TED G. CONCLUSIONS: During LTx, TED-guided fluid management, with norepinephrine used to maintain SVR, was similar to LCVP regarding blood loss and transfusion requirements and had better impacts on kidney function and lactate.

Effect of dexmedetomidine on hepatic ischemia-reperfusion injury in the setting of adult living donor liver transplantation.

OBJECTIVE: The aim of this study was to investigate the hypothesis that intraoperative infusion of dexmedetomidine can exert a protective effect against hepatic ischemia-reperfusion injury (IRI) in adult living donor liver transplantation (LDLiver transplantation). PATIENTS AND METHODS: Forty recipients were allocated into: control group (group I; n = 20) that received a placebo; and dexmedetomidine group (group II; n = 20) that received a continuous intraoperative infusion of 0.8 µg/kg/h of dexmedetomidine. Data collected were AST, ALT, bilirubin, INR, and lactate, at baseline, immediately post-operatively, and on post-operative days 1, 3, and 5. Intercellular adhesion molecule-1 (ICAM-1) was measured at: baseline, 2 and 6 h after reperfusion, and on post-operative day 1. At the end of the surgery, a liver biopsy was sent for histopathological assessment. RESULTS: No significant difference was noticed in either group regarding MELD score, baseline AST, ALT, bilirubin, INR, or lactate. Dexmedetomidine tended to decrease blood pressure and heart rate, but the comparison was insignificant. Group II showed significantly attenuated levels of ICAM-1 and significantly minimal histopathological changes. The laboratory changes showed significantly lower AST, ALT, bilirubin, INR, and lactate in group II. CONCLUSIONS: Dexmedetomidine exerted protective effects against hepatic IRI during adult LDLiver transplantation, as indicated by suppression of ICAM-1, better scores of histopathological assessment, and augmented post-operative liver function tests.

Comparison between intravenous patient controlled analgesia and patient controlled epidural analgesia in cirrhotic patients after hepatic resection.

BACKGROUND: Postoperative pain is one of the most important problems that confront surgical patients. The aim of this work is to compare pain control using intravenous patient controlled analgesia (PCA) and patient controlled epidural analgesia (PCEA) in cirrhotic patients undergoing elective hepatic resection. METHODS: Thirty four adult patients ASAI and II scheduled for liver resection were randomly allocated into two groups-Group (P) with I.V (PCA) with fentanyl and Group (E) (PCEA) via epidural catheter using Bubivacaine 0.125% plus 2 microgram per ml fentanyl. Coagulation changes were followed and pain score was compared in both groups. RESULTS: 34 child A cirrhotic patients, undergoing liver resection were studied. The demographic data were comparable in both groups. There was a significant decrease in pain score in both groups during the follow up period when compared to their initial score. When comparing average pain score between both groups, the PCEA group had significantly lower values. The changes in prothrombin time (PT), INR, and hemoglobin (Hb), were significant all over the follow up period compared to their corresponding base line values. 2 cases needed FFP to normalize the INR for epidural removal. There was no significant difference regarding postoperative nausea and vomiting (PONV) in both groups, no clinical manifestation suggesting epidural hematoma, and no cases were recorded to have respiratory depression. There were no significant differences in patient satisfaction and ICU stay. CONCLUSION: The two modalities of pain control seems to be nearly equivalent, but considering the risk of epidural catheter insertion and removal in cirrhotic patients who are further exposed to hepatectomy with subsequent additional coagulopathy, it may be wise to consider IVPCA technique as a policy for pain management in cirrhotic patient undergoing hepatectomy.

Therapeutic rather than prophylactic platelet transfusion policy for severe thrombocytopenia during liver transplantation.

Platelet transfusion (PTx) has been identified as an important risk factor for morbidity and mortality after liver transplantation (LTx). Our aim was to evaluate the safety of therapeutic rather than prophylactic PTx policy in severe thrombocytopenic patients undergoing LTx. Recipients of LTx were divided into two groups: group I (GI) (n = 76) platelet count (PC) ≥ 50 × 10(9)/l and group II (GII) PC < 50 × 109/l (n = 76). Platelets were transfused following a thromboelastometry protocol and clinical signs of diffuse bleeding. Both groups were compared regarding hemoglobin (Hb), international normalized ratio (INR), fibrinogen level, blood loss (BL), blood products required, percentage of bloodless surgery, duration of mechanical ventilation, ICU stay, and vascular complications. Each group was further subdivided according to PTx into (GI NPTx and GII NPTx) with no platelet transfusion (NPTx) and (GI PTx and GII PTx) received PTx. These subgroups were further compared for some variables. Base line Hb was significantly higher while INR was significantly lower in GI.75% avoided PTx in GII. Comparisons of BL, packed red blood cells (PRBCs), and cryoprecipitate transfusion were insignificant. Fresh frozen plasma (FFP) transfusion was higher and the percentage of bloodless surgery was lower in GII. In GII, PC increased after start of surgery. Two cases of hepatic artery thrombosis in GI and one in GII were recorded. Recovery of platelets was quicker, and duration of mechanical ventilation and ICU stay was shorter in NPTx patients regardless the base line PC. Cut-off values of PC 30 × 10(9)/l (with sensitivity 73.7% and specificity 78.8%, p < 0.01), BL of 3750 ml in GI (sensitivity of 75% and specificity of 69%, p < 0.01) and of 3250 ml in GII (sensitivity of 84.2% and specificity of 87.7% (p < 0.01)) could indicate the need of PTx. With therapeutic approach, 75% of patients in GII could avoid unnecessary PTx with its hazards without excessive bleeding. PC in GII increased intraoperatively, PTx may lead to delayed recovery of platelets, increased duration of mechanical ventilation and ICU stay. The given cut-off values may help to guide PTx.

Transoesophageal Doppler compared to central venous pressure for perioperative hemodynamic monitoring and fluid guidance in liver resection.

PURPOSE: Major hepatic resections may result in hemodynamic changes. Aim is to study transesophageal Doppler (TED) monitoring and fluid management in comparison to central venous pressure (CVP) monitoring. A follow-up comparative hospital based study. METHODS: 59 consecutive cirrhotic patients (CHILD A) undergoing major hepatotomy. CVP monitoring only (CVP group), (n=30) and TED (Doppler group), (n=29) with CVP transduced but not available on the monitor. Exclusion criteria include contra-indication for Doppler probe insertion or bleeding tendency. An attempt to reduce CVP during the resection in both groups with colloid restriction, but crystalloids infusion of 6 ml/kg/h was allowed to replace insensible loss. Post-resection colloids infusion were CVP guided in CVP group (5-10 mmHg) and corrected flow time (FTc) aortic guided in Doppler group (>0.4 s) blood products given according to the laboratory data. RESULTS: Using the FTc to guide Hydroxyethyl starch 130/0.4 significantly decreased intake in TED versus CVP (1.03 [0.49] versus 1.74 [0.41] Liter; P<0.05). Nausea, vomiting, and chest infection were less in TED with a shorter hospital stay (P<0.05). No correlation between FTc and CVP (r=0.24, P > 0.05). Cardiac index and stroke volume of TED increased post-resection compared to baseline, 3.0 (0.9) versus 3.6 (0.9) L/min/m(2), P<0.05; 67.1 (14.5) versus 76 (13.2) ml, P<0.05, respectively, associated with a decrease in systemic vascular resistance (SVR) 1142.7 (511) versus 835.4 (190.9) dynes.s/cm(5), P<0.05. No significant difference in arterial pressure and CVP between groups at any stage. CVP during resection in TED 6.4 (3.06) mmHg versus 6.1 (1.4) in CVP group, P=0.6. TED placement consumed less time than CVP (7.3 [1.5] min versus 13.2 [2.9], P<0.05). CONCLUSION: TED in comparison to the CVP monitoring was able to reduced colloids administration post-resection, lower morbidity and shorten hospital stay. TED consumed less time to insert and was also able to present significant hemodynamic changes. Advanced surgical techniques of resection play a key role in reducing blood loss despite CVP more than 5 cm H2O. TED fluid management protocols during resection need to be developed.