The effect of pre-procedure anxiety on sedative requirements for sedation during colonoscopy.

This study investigated the effects of pre-procedural anxiety (assessed using the Beck Anxiety Inventory) on sedative requirements in 135 patients undergoing sedation for colonoscopy. Deep sedation was defined as loss of consciousness and no response to colonoscopy, and was achieved by target-controlled infusion of propofol. Patients' characteristics, baseline haemodynamic profiles, Beck Anxiety Inventory scores, effect-site propofol concentration at loss of consciousness and characteristics of recovery were recorded. No correlations were found between Beck Anxiety Inventory scores and effect-site propofol concentration at loss of consciousness or baseline haemodynamic profiles. There was no statistical difference in the characteristics of recovery among patients with different levels of anxiety. In conclusion, in patients receiving deep sedation for colonoscopies, the level of pre-procedural anxiety did not relate to the sedative requirement or post-procedural recovery characteristics.

Correlation Between Blood Transfusion and Blood Glucose Levels in Adult Living Donor Liver Transplantation.

BACKGROUND: To evaluate the effect of dextrose contained in banked blood products on the changes of blood glucose levels in adult living donor liver transplantation patients retrospectively. METHODS: Four hundred seventy-seven patients were divided into a non-blood transfusion (BT) group (G1) and a BT group (G2). The changes in blood glucose levels during the operation were compared using a Mann-Whitney U test, and a P value less than .05 was regarded as significant. RESULTS: No significant changes were detected in blood glucose levels after anesthesia, during dissection phase, in the anhepatic phase, or after reperfusion between the groups. Estimated blood loss for G1 (n = 89) and G2 (n = 388) were 718 ± 514 and 5804 ± 877 mL respectively, G1 had no blood transfusion but G2 had received 4350 ± 6230 mL leukocyte-poor red blood cell transfusion, the pre- and end operation hemoglobin for G1 and G2 were 13.2 ± 2.0, 10.2 ± 1.9 and 10.1 ± 1.6, 10.2 ± 1.9 mg/dL respectively, indicating that they were not under or over transfused. CONCLUSION: When banked blood products are used to replace ongoing blood loss, the dextrose contained in citrate-phosphate-dextrose-adenine seems to have no effect on the changes in the blood glucose levels of the recipients.

Comparison of Core Temperature Changes Between Pediatric Patients Lying on Regular Operating Room Linen Drapes and Water-Repellent Sheepskin Rug in Living Donor Liver Transplantation.

OBJECTIVES: The aims of this study were to compare the core temperature changes between pediatric patients lying on regular operating room linen drapes and a water-repellent sheepskin rug during living donor liver transplantation (LDLT) and to evaluate the effectiveness of using a water-repellent sheepskin rug in preventing profound hypothermia due to fluid overflow from the abdominal cavity during LDLT. PATIENTS AND METHODS: The operative records of pediatric patients who underwent LDLT from June 1994-September 2003 were reviewed retrospectively. The nasopharyngeal temperature (NT) changes during the LDLT procedure between patients lying on regular operating room drapes (GI) and water-repellent sheepskin rug (GII) were compared and analyzed using the Mann-Whitney U test. A P value <.05 was regarded as significant. RESULTS: Thirty-two patients were included in GI and 56 in GII. Profound hypothermia was not observed in any recipients lying on a water-repellent sheepskin rug (GII). The NT after induction and the following 4 hours into the LT procedure were significantly higher in GII than GI. CONCLUSION: Pediatric patients lying on water-repellent sheepskin preserved their core temperature better in comparison to patients lying on linen drapes. The use of a water-repellent sheepskin rug seems to be effective in preventing profound hypothermia related to physical contact with abdominal fluid overflow during the LDLT.

Eye Protection in Liver Transplantation Patients Under General Anesthesia.

BACKGROUND: Opsite (Smith & Nephew, Hull, UK) is widely used in wound care but its use in eye protection against corneal abrasion during major surgery is rarely reported. The purpose of the current study is to compare the effectiveness of using Opsite in eye protection with either wet gauze alone or with wet gauze following application of eye ointment in patients undergoing living donor liver transplantation (LDLT). METHODS: This is a prospective, double-blinded, randomized controlled trial. Forty-one patients undergoing liver transplantation were enrolled. One eye of each patient was protected with sterile gauze soaked with normal saline solution and covered with Opsite. Duratears (ALCON, Fort Worth, Tex, United States) ointment was applied to the other eye before covering it with sterile wet gauze and Opsite (ointment group). The corneal examination was carried out after fluorescein staining before and at the end of surgery by the same doctor. A Student t-test and a χ2 test were used for the statistical analyses. RESULTS: Forty-one patients with 82 eyes were observed in this study. No corneal epithelial defects were found in either the normal saline group or the ointment group. CONCLUSION: Opsite combined with wet gauze with or without additional eye ointment provided 100% protection against corneal abrasion in patients undergoing LDLT.

Anesthesia Management and Fluid Therapy in Right and Left Lobe Living Donor Hepatectomy.

OBJECTIVE: Right lobe living donor hepatectomy poses a greater risk for the donor in relation to blood loss. The aims of this study were to compare anesthetic and intraoperative fluid management in right and left lateral segment living donor hepatectomy. PATIENTS AND METHODS: The anesthesia records of living donor hepatectomy patients were retrospectively reviewed. Donor age and weight, anesthesia time, central venous pressure, blood loss, blood product transfusion, intravenous fluids used, doses of furosemide, and urine output were compared and analyzed between groups using the Mann Whitney U test. RESULTS: Forty-six patients underwent living donor left lateral segment hepatectomy (Group I); while 31 patients underwent right lobe hepatectomy (Group II). The mean blood loss in Group II was significantly higher compared to Group I (118 ± 81 mL vs 68 ± 64 mL), but clinically such amount of blood loss was not high enough to affect the hemodynamics. The fluid management was therefore not meaningfully different between the two groups. No blood transfusions or colloid infusions were required for either group. Urine output, hemoglobin changes, blood urea nitrogen, and serum creatinine pre- and postoperatively were not significantly different between groups. CONCLUSIONS: As long as blood loss is minimal, we found no difference in the anesthetic management and fluid replacements between right and left lateral segment living donor hepatectomy.

The Correlation Between CVP and SVV and Intraoperative Minimal Blood Loss in Living Donor Hepatectomy.

BACKGROUND: Blood loss during liver surgery is found to be correlated with central venous pressure (CVP). The aim of the current retrospective study is to find out the cutoff value of CVP and stroke volume variation (SVV), which may increase the risk of having intraoperative blood loss of more than 100 mL during living liver donor hepatectomies. METHOD AND PATIENTS: Twenty-seven adult living liver donors were divided into 2 groups according to whether they had intraoperative blood loss of less (G1) or more than 100 mL (G2). The mean values of the patients' CVP and SVV at the beginning of the transaction of the liver parenchyma was used as the cutoff point. Its correlation to intraoperative blood loss was evaluated using the χ2 test; P < .001 was regarded as significant. RESULTS: The cutoff points of CVP and SVV were 8 mm Hg and 13% respectively. The odds ratio of having blood loss exceeding 100 mL was 91.25 (P < .001) and 0.36 (P < .001) for CVP and SVV, respectively. CONCLUSION: CVP less than 5 mm Hg, as suggested by most authors, is not always clinical achievable. Our results show that a value of less than 8 mm Hg or SVV 13% is able to achieve a minimal blood loss of 100 mL during parenchyma transaction during a living donor hepatectomy. Measurements used to lower the CVP or increased SVV in our serial were intravenous fluids restriction and the use of a diuretic.

Predictive Risk Factors in the Development of Intraoperative Hyperkalemia in Adult Living Donor Liver Transplantation.

BACKGROUND: Hyperkalemia, defined as a serum potassium level higher than 5 mEq/L, is common in the liver transplantation setting. Severe hyperkalemia may induce fatal cardiac arrhythmias; therefore, it should be monitored and treated accordingly. The aim of the current retrospective study is to evaluate and indentify the predictive risk factors of hyperkalemia during living-donor liver transplantation (LDLT). METHODS AND PATIENTS: Four hundred eighty-seven adult LDLT patients were included in the study. Intraoperative serum potassium levels were monitored at least five times during LDLT; patients with a potassium level higher than 5 mEq/L were included in group 1, and the others with normokalemia in group 2. Patients' categorical characteristics and intraoperative numeric variables with a P value <.1 were selected into a multiple binary logistic regression model. In multivariate analysis, a P value of <.05 is regarded as a risk factor in the development of hyperkalemia. RESULTS: Fifty-one of 487 (10.4%) patients had hyperkalemia with a serum potassium level higher than 5.0 mEq/L during LDLT. Predictive factors with P < .1 in univariate analysis (Table 1), such as anesthesia time, preoperative albumin level, Model for End-stage Liver Disease score, preoperative bilirubin level, amount of blood loss, red blood cell (RBC) and fresh frozen plasma transfused, 5% albumin administered, hemoglobin at the end of surgery, and the amount of furosemide used, were further analyzed by multivariate binary regression. Results show that the anesthesia time, preoperative serum albumin level, and RBC count are determinant risk factors in the development of the hyperkalemia in our LDLT serials. CONCLUSION: Prolonged anesthesia time, preoperative serum albumin level, and intraoperative RBC transfusion are three determinant factors in the development of intraoperative hyperkalemia, and close monitoring of serum potassium levels in patients with abovementioned risk factors are recommended.

Relationship Between Patients With or Without a History of Esophageal Varices Bleeding and the Changes in Hemodynamics During Inferior Vena Cava Clamping in Living Donor Liver Transplantation.

BACKGROUND: Whether the history of esophageal variceal bleeding (EVB) can be used clinically to predict the tolerability or hemodynamic instability during clamping of the inferior vena cava (IVC) and portal vein in liver transplantation is unknown and, therefore, needs to be elucidated. PATIENTS AND METHODS: A total of 50 anesthesia charts of patients who underwent living donor liver transplantation were reviewed, analyzed and compared retrospectively. Patients without a history of EVB were classified as group 1 and patients with a history of EVB were classified as group 2. The numbers of patients with a decrease in cardiac index (CI) of ≥20%, ≥30%, or ≥40% from their preclamping values after IVC clamping were compared with a χ(2), and a P value of .05 was regarded as statistically significant. RESULTS: The measured hemodynamic parameters before and 5 minutes after clamping of the IVC and portal vein were all significantly different in comparison with the patient's preclamping values. The incidence of a decrease in CI of ≥20%, ≥30%, or ≥40% 5 minutes after clamping of the IVC and portal vein were not significantly different between groups. CONCLUSIONS: Clamping of the portal vein and IVC without performing veno-venous bypass in living donor liver transplantation had a significant negative impact on CI in both groups due to the drastic reduction in the venous return. Statistical analysis revealed that a history of EVB affects hemodynamics in a manner similar to that in patients without history of EVB during IVC clamping.

Preoperative Portal Vein Velocity/Size and Effect on Living Donor Liver Transplantation Recipient Hemodynamics During Inferior Vena Cava Clamping.

BACKGROUND: The aim of this study is to determine whether preoperative portal vein flow velocity or size has any correlative effect on hemodynamic changes during clamping of the inferior vena cava in liver transplantation. PATIENTS AND METHODS: A total of 42 anesthesia charts of adult patients who underwent living donor liver transplantation (LDLT) were analyzed and compared retrospectively. Preoperative portal vein (PV) flow velocity and sizes were obtained using Doppler ultrasound. All changes in the hemodynamic data before and after clamping of the portal vein (PV) and inferior vena cava (IVC) were recorded and analyzed by linear regression. A P value of <.05 was considered significant. RESULTS: Heart rate (HR), mean arterial blood pressure (MAP), central venous pressure (CVP), cardiac output (CO), cardiac index (CI), and stroke volume (SV) before and after clamping of the PV and IVC were significantly different for as long as the PV and IVC were clamped. Linear regression analysis indicated that R2 of HR, MAP, CVP, CO, and CI in correlation with the PV velocity were 0.002, 0.035, 0.024, and 0.001; R2 of the PV diameter for HR, MAP, CVP, CO, and CI were 0.028, 0.01, 0.034, and 0.004. The changes in the percentages of cardiac output at 1- and 5-minute intervals after IVC clamping were not correlated significantly with either the preoperative flow velocity or the size of the PV. CONCLUSION: Preoperative PV flow velocity and size are not correlated or associated with hemodynamic changes during IVC clamping in liver transplantation.

Transitional Study of Patient-Controlled Analgesia Morphine With Ketorolac to Patient-Controlled Analgesia Morphine With Parecoxib Among Donors in Adult Living Donor Liver Transplantation: A Single-Center Experience.

BACKGROUND: In this study, as our center transitions from using patient-controlled analgesia (PCA) morphine with intravenous (IV) ketorolac to PCA morphine with IV parecoxib, the two regimens are compared in terms of quality of pain control. METHODS: Post-operative pain management sheets were collected retrospectively among the living donors of liver transplantation during this transitional period. Group parecoxib was given plain PCA morphine. A single dose of IV parecoxib 40 mg was given 30 minutes before the end of surgery. Group ketorolac was given PCA morphine pre-mixed ketorolac with a concentration of 1.87 mg/mL. Daily and total morphine consumption, Visual Analog Score (VAS), and number of rescue attempts made up to 3 post-operative days, together with satisfaction score and incidence of side effects of PCA usage, were analyzed and compared by means of the Mann-Whitney U test; a value of P < .05 was regarded as significant, and data are given as mean ± SD. RESULTS: Fifty patients were analyzed; group 1 comprised 21 patients and group 2 comprised 29 patients. There was no difference between group 1 and group 2 in terms of daily VAS. PCA morphine requirements were significantly lower at day 2 and day 3 in group 1. However, the total overall morphine usage and satisfactory score was not statistically different (P = .863, P = .052). CONCLUSIONS: A single dose of IV parecoxib 40 mg can provide satisfactory pain control when paired with PCA morphine for donors undergoing living donor liver transplantation. The use of parecoxib in the multimodal analgesia regimen has similar efficacy, with possibly less morphine consumption, when compared with ketorolac.

Correlation Between Changes in End-Tidal Carbon Dioxide Concentration and Cardiac Output During Inferior Vena Cava Clamping and Unclamping in Living-donor Liver Transplantation.

BACKGROUND: To test the hypothesis that low end-tidal carbon dioxide tension encountered during anhepatic phase in liver transplantation is related to hemodynamic status rather than ventilatory status, and can be used to predict the change in cardiac output during anhepatic phase. METHODS: We retrospectively analyzed and compared data, included end-tidal carbon dioxide tension (ETCO2), arterial blood pressure, heart rate, central venous pressure, cardiac output, cardiac index, and stroke volume, before and after inferior vena cava clamping, and 0, 5, 10, 30 minutes during the anhepatic, and 5 minutes after the release of IVC cross clamp during the reperfusion phase, with paired Student t test, repeated measurement, and linear regression. P < .05 was regarded as significant. RESULTS: The cardiac output and ETCO2 decrease significantly after clamping the inferior vena cava and increase concomitantly after unclamping. There is a positive correlation between the changes in % in cardiac output and ETCO2 (Pearson coefficient r = 0.741). CONCLUSION: The changes in ETCO2 can be used to predict the changes of the cardiac output in % when cardiac output monitoring is not available. Before unclamping of the IVC, mild hyperventilation is suggested to prevent excessive increase in PaCO2.

Effects of Pre-Existing Liver Disease on Acute Pain Management Using Patient-Controlled Analgesia Fentanyl With Parecoxib After Major Liver Resection: A Retrospective, Pragmatic Study.

BACKGROUND: The aim of this study was to compare the outcomes of pain management with the use of patient-controlled analgesia (PCA) fentanyl with IV parecoxib between patients with healthy liver with patients with diseased liver undergoing major liver resection. METHODS: Patients with healthy liver undergoing partial hepatectomy as liver donors for liver transplantation (group 1) and patients with liver cirrhosis (Child's criteria A) undergoing major liver resection for hepatoma (group 2) were identified retrospectively. Both groups routinely received post-operative IV PCA fentanyl and a single dose of parecoxib 40 mg. They were followed up for 3 days or until PCA fentanyl was discontinued post-operatively. Daily Visual Analog Scale, PCA fentanyl usage, rescue attempts, and common drug side effects were collected and analyzed with the use of SPSS version 20. RESULTS: One hundred one patients were included in the study: 54 in group 1, and 47 in group 2. There were no statistical differences between the two groups in terms of the daily and total fentanyl usage, VAS resting, and incidence of itchiness. The rate of rescue analgesia on post-operative day (POD) 1 was lower in group 2, with a value of P = .045. VAS dynamics were better on POD 1 and 2 for group 2, with P = .05 and P = .012, respectively. CONCLUSIONS: We found that combining a single dose of IV parecoxib 40 mg with PCA fentanyl is an easy and effective method of acute pain control after major liver resection. We propose the careful usage of post-operative fentanyl and parecoxib in patients with diseased liver, given the difference in effect as compared with healthy liver.

Retrospective Cohort Study to Compare Anesthesia in Living Donor Liver Transplantation Recipients Who Received Single and Dual Liver Grafts.

OBJECTIVE: Dual graft living donor liver transplantation (LDLT) is an alternative way to overcome small-for-size syndrome in LDLT. Surgical technique and outcome of using dual grafts have been reported, but there are no reports regarding anesthetic management. The aim of the current study is to compare the anesthetic management of single graft and dual graft liver transplantation. METHODS AND PATIENTS: Anesthesia records of 24 single graft liver transplantation recipients (GI) and 6 dual graft recipients (GII) were reviewed, analyzed, and compared retrospectively. Patient characteristics and intraoperative data between groups were compared with Mann-Whitney t test and Fisher's exact test where appropriate. P value less than .05 was regarded as significant. RESULTS: Patient characteristics and most of the intraoperative data were similar between groups. Significant difference was noted in the total anesthesia time and the anhepatic time. Both times were significantly longer in GII compared to GI. CONCLUSION: Dual graft living donor liver transplantation is surely a technically more challenging and demanding procedure. Therefore the total anesthesia time is longer, especially the anhepatic phase, because there are more graft vessels to be reconstructed before reperfusion. Overall the anesthetic management in terms of blood transfusion, fluid administration, sodium bicarbonate, calcium supplement, and the number of patients requiring fractional diluted noradrenaline support for maintenance of acceptable hemodynamic were not much different between the 2 groups.

Effect of university of wisconsin and histidine-tryptophan-ketoglutarate preservation solutions on blood potassium levels of patients undergoing living-donor liver transplantation.

BACKGROUND: The potassium content of University of Wisconsin solution (UW) is 125 mEq/L and that of histidine-tryptophan-ketoglutarate solution (HTK) only 9 mEq/L. The aim of the present study was to analyze their effects to change potassium levels on reperfusion among patients undergoing living-donor liver transplantation. METHODS: Anesthesia records of adult living-donor liver transplant patients were reviewed retrospectively. Patients received liver graft preserved in UW were grouped in group I (GI) and HTK in group II (GII). The potassium levels in the anheptic phase were compared with those 5 minutes after reperfusion using paired Student t tests. P values of <.05 were regarded to be significant. RESULTS: Eighty-five GI patients showed the potassium significantly decreased from 3.76±0.70 to 3.60±0.74, whereas the change among 355 GII patients was almost unremarkable: 4.00±0.57 to 3.96±0.06 mEq/L. CONCLUSIONS: Although UW contains a higher potassium content, it seems to have no negative impact on changes in serum potassium levels; in contrast it decreased the potassium level significantly at 5 minutes after reperfusion. Both preservation solutions maintain the patients' potassium levels within the normal range.