Detection and quantification of perioperative heparin-like effects by rotational thromboelastometry in living-donor liver transplant recipients: A prospective observational study.

Background and Aims: Heparin-like effects (HLEs) can affect hemostasis during liver transplantation. The aim of this study was to assess the perioperative incidence and severity of HLE with rotational thromboelastometry (ROTEM) and activated partial thromboplastin time (aPTT). Material and Methods: ROTEM and aPTT were measured intraoperatively and on postoperative days (POD) 1, 3, and 7. HLE was identified if ROTEM INTEM/HEPTEM CT-ratio was >1.25 and severe forms of HLE when ratio was ≥2. Based on aPTT, HLE was defined when aPTT ratio was >1.25 (patient aPTT/control aPTT). Results: Thirty-eight recipients were included. Variable degrees of HLE were detected by aPTT-ratio and INTEM/HEPTEM CT ratio. No significant correlation existed between both ratios. Based on INTEM/HEPTEM CT ratio, HLE was detected in 7/38 during anhepatic phase, 19/38 post-reperfusion, 10/38 on POD1, 4/38 on POD3, and 0/38 on POD7. Four cases of severe HLE were identified by INTEM/HEPTEM CT ratio only in the anhepatic phase. Postoperative infusion of unfractionated heparin led to mild-moderate HLE on POD1 and 3 as evident by both tests. Red blood cell and plasma transfusion were higher with severe HLE (1350 ± 191 ml and 3558 ± 1407 ml). Composite adverse outcome of any complication or death within 3 months for patients without HLE, mild-moderate HLE, and severe HLE as detected by ROTEM was 27.8%, 42.9%, and 66.7%, respectively. Conclusion: INTEM/HEPTEM CT ratio was able to detect and quantify HLE as aPTT ratio. The ability of the INTEM/HEPTEM CT ratio to identify severe HLE earlier in the anhepatic phase needs to be studied in a larger population. HLE is self-limiting, but when identified in a severe form, it is associated with worse outcome.

Monitoring haemodynamic changes during transjugular portosystemic shunt insertion with electric cardiometry in sedated and spontaneous breathing patients. A diagnostic test accuracy study.

Background and Aims: Transjugular intrahepatic portosystemic shunt (TIPS) allows a high blood volume into systemic circulation abruptly. The primary aim of the study was to investigate the effect of TIPS on systemic, portal hemodynamics, and electric cardiometry (EC) parameters in sedated and spontaneous breathing patients. Secondary aims?? Material and Methods: Adult consecutive hepatic patients scheduled for elective TIPS were included. Patients were sedated with bispectral index-guided propofol infusion + fentanyl boluses. EC parameters, i.e., cardiac output (CO) and systemic vascular resistance (SVR) were noted. Noninvasive blood pressure, heart rate, central venous pressure (CVP, cmH2O), and portal venous pressure (PVP, cmH2O) were measured pre- and post-TIPS. Results: Thirty-six people were enrolled (n = 25 included) from Aug 2018 to Dec 2019. Data (expressed in median (IQ)) were: age 33 (27-40) years, body mass index 24 (22.0-27) kg/m2, child A 60%, B 36%, and C 4%. Post-TIPS, PVP decreased (from 40 [37-45] to 34 [27-37] mmHg, P < 0.001), whereas CVP increased (from 7 [4-10] to 16 [10.0-19.0] mmHg, P < 0.001). The CO increased (P = 0.03) and SVR reduced (P = 0.012). Conclusion: The reduction in PVP following successful TIPS insertion elevated the CVP abruptly. EC was able to monitor an immediate increase in the CO and a reduction in SVR in association with the above PVP and CVP changes. The results of this unique study indicate that EC monitoring is promising; however, further evaluation in a larger population and in correlation with other gold-standard CO monitors is still indicated.

Monitoring the effects of automated gas control of sevoflurane versus target-guided propofol infusion on hemodynamics of liver patients during liver resection. A randomized controlled trial.

Background and Aims: Cirrhotic patients are prone to hypotension during anesthesia. The primary aim of the study was to compare the effects of automated gas control (AGC) of sevoflurane and target-controlled infusion (TCI) of propofol on systemic and cardiac hemodynamics in hepatitis C cirrhotic patients undergoing surgery. The secondary aim was to compare the recovery, complications, and costs between the two groups. Material and Methods: This was a randomized controlled trial in adults with hepatitis C cirrhosis (Child A) who underwent open liver resection and received AGC (n = 25) or TCI (n = 25). AGC was initially set at FiO2 40% and end-tidal sevoflurane (ET SEVO) at 2.0% with a fresh gas flow of 300 mL/min. TCI of propofol was given using Marsh pharmacokinetic mode with an initial propofol target concentration (Cpt) of 4 µg/mL. Bispectral index score (BIS) was maintained between 40 and 60. Invasive arterial blood pressure (IBP), electrical cardiometry (EC), cardiac output (CO), and systemic vascular resistance (SVR), Fi SEVO, ET SEVO, propofol Cpt, and effect-site concentration (Ce) were recorded. Results: IBP and EC CO, and SVR were least affected by TCI propofol. Only one (4.00%) patient required vasopressors with TCI vs. 4 (16.00%) with AGC (χ2 (Y) (df = 1) = 0.88, P (Y) = 0.34). There was no delayed recovery, hypoxia, or awareness; however, ICU stay was shorter with TCI, (P = 0.006). BIS and EC guided median of ET SEVO was 1.90%, Fi SEVO was 2.10% with AGC, and propofol Cpt and Ce were 3.00 µg/dL with TCI. Only 0.14 [0.12-0.15] mL/min of SEVO was consumed with AGC and 0.87 [0.85-0.97] mL/min propofol with TCI. The cost was higher with TCI, P < 0.00. Conclusions: Both techniques are well tolerated hemodynamically, but TCI-propofol was found to be hemodynamically better. The recovery and complications were comparable in both groups, but TCI Propofol infusion was costlier.

Impact of terlipressin infusion during and after live donor liver transplantation on incidence of acute kidney injury and neutrophil gelatinase-associated lipocalin serum levels: A randomized controlled trial.

BACKGROUND AND AIM: Acute kidney injury (AKI) with liver transplantation (LT) is not uncommon. Impact of terlipressin infusion on AKI, hemodynamics, and plasma concentration of neutrophil gelatinase-associated lipocalin (NGAL) was studied. METHODS: Patients (n=50) were randomized (NCT02059460, USA) into two equal groups: terlipressin vs Controls. Terlipressin (1-4 µg/kg/h) was administrated for 5 days. Intraoperative transesophageal Doppler for hemodynamic management. Renal functions, peak portal vein blood flow velocity (PPV), and hepatic artery resistive index (HARI) were recorded. Plasma NGAL (pNGAL) was measured baseline, 2 and 24 hours postreperfusion. RESULTS: Hepatitis C virus (HCV) was the main etiology. Age, sex, model of end-stage liver disease (MELD), and renal functions were comparable. Postoperative AKI incidence and NGAL concentrations were comparable (P>.05) between terlipressin and controls groups (44% vs 48% and 112.5±9 vs 93.1±8 ng/mL), respectively, but intraoperative NGAL in both groups increased significantly 2 hours postreperfusion (P<.05). The three NGAL readings were comparable (P>.05) between AKI (n=23) and non-AKI developers (n=27). Mean arterial blood pressure (MAP) was maintained in both groups with less systemic vascular resistance (SVR) fluctuations with terlipressin. Median norepinephrine consumption was lower in terlipressin vs controls (8 vs 12 mg; P=.04). The PPV and HARI were not affected by terlipressin at any stage (P>.05). CONCLUSION: Postliver transplant AKI was not prevented by terlipressin use nor predicted by NGAL levels.

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.

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.

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.

Entropy-guided end-tidal desflurane concentration during living donor liver transplantation.

BACKGROUND: The three phases of living donor liver transplantation (LDLT) represent different liver conditions. The aim is to study the required end-tidal desflurane concentration (ET-Des) guided with entropy monitoring for the depth of anesthesia. METHODS: After the Ethics and Research Committee approval, 40 patients were included in this prospective study. Anesthesia was maintained with Desflurane-O2-air. State entropy (SE) and Response entropy (RE) were kept between 40 and 60. RESULTS: Age and Model for End-stage Liver Disease (MELD) score were 45±10 years and 15.43±3.92, respectively. ET-Des were significantly lower in the anhepatic phase (2.8±0.4%) than in the pre-anhepatic and neohepatic phases (3.3±0.3%, 3.47±0.3%, respectively, P<0.001). The SE and RE for pre-anhepatic, anhepatic, and neohepatic phases were (45.6±3.7, 47.4±3.2), (44.7±2.1, 46.4±2.04), and (46.1±3.3, 47.9±3.3), respectively, with no significant changes between the phases, P > 0.05. Total operative time was 651±88 minutes, and for each phase it was 276±11, 195±55, and 191±24 minutes, respectively. Significant changes were found in hemoglobin g/dl and hematocrit % between the three phases (10.28±1.5, 30.48±4.3), (9.45±1.34, 28.36±4.1), and (8.88±1.1, 26.63±3.5), P<0.05. The heart rate and mean blood pressures were stable despite the cardiac index demonstrated a significant reduction during the anhepatic phase (2.99±0.22) when compared to the pre-anhepatic and neohepatic phases (3.60±0.29) and (4.72±0.32), respectively, (P<0.05). There was a significant correlation between CI and ET-Des% (r=0.604, P<0.05). CONCLUSION: Inhalational anesthetic requirements differed from one phase to another during LDLT, with requirements being the least during the anhepatic phase. Monitoring of the anesthesia depth was required, to avoid excess administration, which could compromise the hemodynamics before the critical time of reperfusion.