Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial.

BACKGROUND: Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS: This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 mL as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS: The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION: The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION: This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

Comparative outcomes of pure laparoscopic and open donor right hepatectomy: the first report from a Southeast Asian transplant center.

BACKGROUND: Pure laparoscopic donor right hepatectomy (PLDRH) can provide better operative outcomes for the donor than conventional open donor right hepatectomy (CODRH). However, the complexity of the procedure typically makes transplant teams reluctant to perform it, especially in low-volume transplant centers. We compared the outcomes of PLDRH and CODRH to demonstrate the feasibility of PLDRH in a low-volume transplant program. METHODS: We carried out a retrospective study of adult living donor liver transplantation in Chiang Mai University Hospital from January 2015 to March 2021. The patients were divided into a PLDRH group and a CODRH group. Baseline characteristics, operative parameters, and postoperative complications of donors and recipients were compared between the two groups. RESULTS: Thirty patients underwent donor hepatectomy between the dates selected (9 PLDRH patients and 21 CODRH patients). The baseline characteristics of the 2 groups were not significantly different. The median graft volume of the PLDRH group was 693.8 mL, which was not significantly different from that of the CODRH group (726.5 mL) The PLDRH group had a longer operative time than the CODRH group, but the difference was not statistically significant (487.5 min vs 425.0 min, p = 0.197). The overall complication rate was not significantly different between the two groups (33.3% vs 22.2%, p = 0.555). Additionally, for the recipients, the incidence of major complications was not significantly different between the groups (71.3 vs 55.6%, p = 0.792). CONCLUSION: Even in the context of this low-volume transplant program, whose staff have a high level of experience in minimally invasive hepatobiliary surgery, PLDRH showed similar results to CODRH in terms of perioperative outcomes for donors and recipients.

Consensus on the Southeast Asian management of hypotension using vasopressors and adjunct modalities during cesarean section under spinal anesthesia.

BACKGROUND AND AIMS: This consensus statement presents a comprehensive and evidence-based set of guidelines that modify the general European or US guidelines for hypotension management with vasopressors during cesarean delivery. It is tailored to the Southeast Asian context in terms of local human and medical resources, health system capacity, and local values and preferences. METHODS AND RESULTS: These guidelines were prepared using a methodological approach. Two principal sources were used to obtain the evidence: scientific evidence and opinion-based evidence. A team of five anesthesia experts from Vietnam, the Philippines, and Thailand came together to define relevant clinical questions; search for literature-based evidence using the MEDLINE, Scopus, Google Scholar, and Cochrane libraries; evaluate existing guidelines; and contextualize recommendations for the Southeast Asian region. Furthermore, a survey was developed and distributed among 183 practitioners in the captioned countries to gather representative opinions of the medical community and identify best practices for the management of hypotension with vasopressors during cesarean section under spinal anesthesia. CONCLUSIONS: This consensus statement advocates proactive management of maternal hypotension during cesarean section after spinal anesthesia, which can be detrimental for both the mother and fetus, supports the choice of phenylephrine as a first-line vasopressor and offers a perspective on the use of prefilled syringes in the Southeast Asian region, where factors such as healthcare features, availability, patient safety, and cost should be considered.

Adult-to-Adult Living Donor Liver Transplantation: Postoperative Outcomes and Quality of Life in Liver Donors: First Report in Thailand.

BACKGROUND: Deceased donor liver transplantation is a rare procedure in Northern Thailand because of cultural issues. Living donor liver transplantation (LDLT) can decrease waiting list mortality for the patients who have end-stage liver disease. In Thailand, our center is the only active adult-to-adult LDLT program. This study is the first report of outcomes and health-related quality of life in liver donors. OBJECTIVES: The aim of this study was to evaluate the postoperative outcomes and health related quality of life in living liver transplant donors at the Transplant Center in Thailand. MATERIALS AND METHODS: All patients undergoing liver resection for adult-to-adult LDLT at our center between March 2010 and July 2018 were evaluated in a cross-sectional study. The effect of donor demographics, operative details, postoperative complications (Clavien-Dindo classification), hospitalization, and health related quality of life was evaluated through health-related quality of life questionnaires (short-form survey, SF-36) RESULTS: A total of 14 donor patients were included in this study with an age range from 26 to 51 years (mean 39.86 years, standard deviation [SD] = 8.59 years). The patients were 71.43% female and 28.57% male. The majority of patients had primary and secondary education (57.14%) and were married (64.29%). After hepatectomy, there was no mortality in the evaluated donors. The Clavien-Dindo classification of postoperative complications were as follows: Grade I (none), Grade II (50%), Grade IIIa (7.14%), and Grade IIIb (7.14%). The serum levels of total protein and albumin were decreased on postoperative day 5. The hospital stays averaged 11.5 days (SD = 4.9 days) and ranged from 5 to 22 days. After considering each aspect of the donors' postoperative quality of life, the highest mean score was related to physical composite scores in physical roles with a mean of 96.42 (SD = 13.36) and physical function with a mean of 95.35 (SD = 13.36). Moreover, the mental composite scores in social function was the highest mean of 91.96 (SD = 12.60) and role emotion was a mean of 90.47 (SD = 27.51). CONCLUSIONS: Living donor hepatectomy was safe, with an acceptable morbidity, and recognized as a safe procedure with an excellent long-term health quality of life.

Price to pay; Portal vein arterialization for hepatic artery thrombosis after living donor liver transplantation; A case report.

OBJECTIVE: Hepatic artery thrombosis (HAT) is one of the most serious complications of liver transplantation that can potentially lead to loss of the allograft. Retransplantation is the only option when revascularization can't be performed but the donor may be not available in the short period of time. We report the technique of using portal vein arterialization (PVA) for bridging before retransplantation. There are few reports in living donor setting. CASE DESCRIPTION: The recipient of the liver was a 59 year old male who received an extended right lobe graft from his son. Post operative day 41, HAT was diagnosed from angiogram and liver function got rapidly worse. We decided to re-anastomose the hepatic artery but this was not possible due to a thrombosis in the distal right hepatic artery. So PVA by anastomosis of the common hepatic artery to splenic vein was performed. During the early postoperative period liver function gradually improved. Unfortunately, he died from massive GI hemorrhage one month later. DISCUSSION: PVA has previously been reported as being useful when revascularization was not successful. The surgical technique is not complicated and can be performed in sick patient. Liver graft may be salvaged with oxygenated portal flow and recover afterwards. However, portal hypertension after PVA seem to be an inevitable complication. CONCLUSIONS: PVA may be a bridging treatment for retransplantation in patients whom hepatic artery reconstruction is impossible after HAT. Regards to the high morbidity after procedure, retransplantation should be performed as definite treatment as soon as possible.

Lacerated Liver Graft in an Open Abdomen Setting: A Case Report.

Donor scarcity is a primary problem in the development of a transplant program. The imbalance between an extremely increasing demand and the number of organs in the supply has led to an extended criteria donor approach. The successful use of donors with infectious diseases and septic shock has been reported. However, organs from deceased donors with traumatic abdominal injury and open abdomen are usually discarded due to risks of severe infections. Thus far, only 1 such case, in which a liver graft from an open abdomen was used successfully, has been reported. Herein, we report of a case of liver transplant using a traumatized liver allograft procured from a deceased donor with an open abdomen. The donor was a 16-year-old patient who had blunt abdominal trauma and severe head injury from a car accident, resulting in emergency laparotomy with suturing of the lacerated wound at the liver and abdominal packing. The donor was subsequently pronounced brain dead, and the family consented to organ donation. A multiorgan procurement was performed, and the liver was transplanted to 52-year-old patient who had multiple hepatocellular carcinomas. The postoperative course was without any infection or rejection. In conclusion, the use of donor livers with preexisting trauma in open abdomen settings can be used as alternative to expand the organ donor pool.

Huge cardiac myxoma in pregnancy.

A 28-year-old pregnant woman presented at 28 weeks of gestation. She was diagnosed to have a left atrial myxoma 2 years earlier, but was lost to follow-up. During this pregnancy, the transthoracic echocardiography showed a 9 cm mass in the left atrium obstructing mitral valve inflow, interfering with mitral valve closure, causing severe mitral regurgitation and severe pulmonary hypertension. However, there were no clinical signs of pulmonary and systemic congestion or obstruction. Based on the clinical symptoms of the patient, the echocardiographic findings and the term of her pregnancy, the patient decided to schedule for a vaginal delivery with surgical correction after delivery. She gave birth at 32 weeks of gestation. During labour, pulmonary oedema developed but was detected early and it responded to therapy. Two weeks after delivery, a right anterior thoracotomy was performed to facilitate the removal of the left atrial myxoma and repair of the mitral valve.

The use of a volatile anesthetic regimen protects against acute normovolemic hemodilution induced myocardial depression in patients with coronary artery disease.

BACKGROUND: Previous studies indicated that acute normovolemic hemodilution (ANH) was associated with a depression of myocardial function in coronary surgery patients with baseline heart rate faster than 90 bpm. It was suggested that this phenomenon could be explained by the occurrence of myocardial ischemia. In the present study, we hypothesized that the cardioprotective properties of a volatile anesthetic regimen might protect against the ANH related myocardial functional impairment. MATERIALS AND METHODS: Forty elective coronary surgery patients with baseline heart rate faster than 90 bpm were randomly allocated to receive different anesthetic regimens. Group A (n = 20) received midazolam-based anesthesia. Group B (n = 20) received a sevoflurane-based anesthesia. Five-lead electrocardiogram, pulse oximetry, capnography, radial arterial pressure, and Swan Ganz continuous thermodilution cardiac output via right internal jugular vein were monitored. Measurements were obtained before and after ANH. Data were compared using paired t test. All data were expressed as mean +/- SD. Data were considered significant if P < 0.05. RESULTS: After ANH, systemic vascular resistance was slightly decreased in group A while there was a significant decrease in group B. In group A, cardiac output was slightly decreased from 5.07+/-1.17 l/min to 5.02+/-1.28 l/min after ANH, whereas in group B, cardiac output was significantly increased from 4.84+/-1.21 l/min to 6.02+/-1.28 l/min after ANH. CONCLUSION: In coronary surgery patients, with baseline heart rate faster than 90 bpm, anesthesia with sevoflurane during ANH was associated with an improvement in myocardial function after ANH, which was not present in patients anesthetized with midazolam.

A randomized trial evaluating different modalities of levosimendan administration in cardiac surgery patients with myocardial dysfunction.

OBJECTIVE: To evaluate the effects of 2 different administration modalities of levosimendan (start before cardiopulmonary bypass [CPB] and at the end of CPB) compared with a standard treatment with milrinone started at the end of CPB in cardiac surgery patients with a preoperative ejection fraction <30%. DESIGN: A prospective study. SETTING: A university hospital. PARTICIPANTS: Sixty patients undergoing elective cardiac surgery with CPB. INTERVENTIONS: Patients were randomly assigned to 3 different treatment options for weaning from CPB after cardiac surgery. Group A received milrinone, 0.5 microg/kg/min, after the release of the aortic cross-clamp; group B received levosimendan, 0.1 microg/kg/min, after the induction of anesthesia; and in group C, levosimendan, 0.1 microg/kg/min, was started immediately after the release of the aortic cross-clamp. In all patients, additional dobutamine, 5 microg/kg/min, was initiated after the release of the aortic cross-clamp. Norepinephrine maintained mean arterial pressure constant. MEASUREMENTS AND MAIN RESULTS: Stroke volume after surgery was initially higher than at baseline in all groups and highest in group B. Stroke volume declined 12 hours after surgery in group A but not in groups B and C (p < 0.05 between groups), despite similar filling pressures. Four patients in group A, none in group B, and 1 in group C died within 30 days of surgery. Postoperative atrial fibrillation was observed in 10 patients in group A, 7 patients in group C, and only 1 in group B (p < 0.01). No differences were observed in postoperative troponin I release among groups. CONCLUSION: In the conditions of the present study, starting the levosimendan treatment before CPB was associated with a higher initial postoperative stroke volume and a lower incidence of postoperative atrial fibrillation, but had no effect on the extent of postoperative troponin I release.

Moderate acute isovolemic hemodilution alters myocardial function in patients with coronary artery disease.

BACKGROUND: Although moderate hemodilution is usually well tolerated in coronary artery surgery patients, this may not be the case when myocardial oxygen demand is increased. We hypothesized that, in these patients, hemodilution in the presence of an increased heart rate could be associated with an impairment of myocardial function. METHODS: Forty coronary surgery patients were randomly assigned to two groups (n=20), according to the rate of atrioventricular pacing [70 bpm (Group 70) or 90 bpm (Group 90)]. While paced at the fixed heart rate, hemodilution was performed before the start of cardiopulmonary bypass. Data were obtained from a pulmonary artery, a PiCCO catheter and a left ventricular pressure catheter. Measurements were obtained in steady-state conditions before and after isovolemic hemodilution. RESULTS: Hemodilution from 40%+/-2% to 30%+/-1% in Group 70, and from 39%+/-4% to 30%+/-2% in Group 90 resulted in a decrease in systemic vascular resistance and an increase in end-diastolic volume in both groups. This was associated with an increase in stroke volume in Group 70 but not in Group 90. In this latter group, the maximal rate of pressure development decreased significantly after hemodilution [from 856+/-93 to 716+/-80 mm Hg/s (P<0.01)], whereas it remained unchanged in Group 70 (843+/-86 mm Hg/s before and 832+/-79 mm Hg/s after hemodilution). CONCLUSIONS: In the conditions of the present study, increased heart rate during moderate hemodilution was associated with a depression of myocardial function.

Cardioprotection with volatile anesthetics in cardiac surgery.

Myocardial ischemia during the perioperative period is a major cause of morbidity and mortality after surgery. Experimental data indicate that clinical concentrations of volatile anesthetics protect the myocardium from ischemia and reperfusion injury, as shown by decreased infarct size and more rapid postoperative recovery of contractile function. These anesthetics may also mediate protective effects in other organs, such as the brain and kidney. A number of recent reports have indicated that these experimentally observed protective effects might also be present in the clinical setting. Implementation of such cardioprotection during surgery may provide an additional tool in the treatment and prevention of ischemic cardiac dysfunction in the perioperative period. This review discusses the clinical studies that have focused on the potential cardioprotective effects of volatile anesthetic agents.

Uncalibrated arterial pulse contour analysis versus continuous thermodilution technique: effects of alterations in arterial waveform.

OBJECTIVE: To compare an arterial pressure-derived cardiac output (APCO) (Vigileo software version 1.07; Edwards Lifesciences, Irvine, CA) and a thermodilution cardiac output (CCO) as methods for measuring cardiac output under different pathologic and experimental conditions that induce changes in arterial waveform morphology. DESIGN: A prospective study. SETTING: A university hospital, single institutional. PARTICIPANTS: Fifty-two patients undergoing elective cardiac surgery. INTERVENTIONS: Simultaneous APCO and CCO were compared in low-risk patients undergoing elective coronary artery surgery (without valvular disease) (control, n = 20), patients with aortic stenosis (AS, n = 10), aortic insufficiency (AI, n = 10), and intra-aortic balloon pump (IABP, n = 12). In the control group, additional data were registered before and after median sternotomy and phenylephrine administration. MEASUREMENTS AND MAIN RESULTS: In the control group, Bland-Altman showed a bias of -3% (95% limits of agreement: -59% to +53%) before cardiopulmonary bypass (CPB) and of -1% (95% limits of agreement: -51% to +50%) after CPB. In the AS group, the bias was -5% (95% limits of agreement: -34% to +24%) before CPB and 1% (95% limits of agreement: -28 to +30%) after CPB. In the AI group bias was +32% (95% limits of agreement: -4% to +68%) before CPB and -2% (95% limits of agreement: -35% to +32%) after CPB. Median sternotomy decreased CCO by 10% +/- 10%, whereas it increased APCO by 56% +/- 28%. Phenylephrine administration decreased CCO by 11% +/- 16%, whereas it increased APCO by 55% +/- 34%. CONCLUSIONS: Cardiac output measurement based on uncalibrated pulse contour analysis is able to reflect cardiac output measured with the continuous thermodilution method in patients undergoing uncomplicated coronary artery surgery. However, in situations in which the arterial pressure waveform is changed, agreement between techniques may be altered and data obtained with uncalibrated pulse contour analysis may become less reliable.

Inferior vena cava diameter and central venous pressure correlation during cardiac surgery.

OBJECTIVE: The purpose of this study was to determine whether a relationship exists between the inferior vena cava diameter (IVCD) or the superior vena cava diameter (SVCD) measured at the point of entry into the right atrium using transesophageal echocardiography (TEE) and the central venous pressure (CVP) under different experimental conditions. DESIGN: Prospective study. SETTING: University hospital, single institution. PARTICIPANTS: Seventy patients undergoing elective cardiac surgery. INTERVENTIONS: CVP, IVCD, and SVCD were measured in a 2-dimensional, long-axis midesophageal bicaval view at end-diastole with electrocardiographic synchronization. Data were recorded during suspended ventilation, before and after leg elevation, and at different levels of positive end-expiratory pressure (0, 5, and 10 cmH(2)O). MEASUREMENTS AND MAIN RESULTS: The relationship between IVCD and CVP had 2 portions: A first (CVP 11 mmHg) in which the correlation was poor (R = 0.272, p = 0.065). No correlation between SVCD and CVP was observed. CONCLUSION: A strong correlation between TEE-derived IVCD measured at the point of entry into the right atrium and CVP was observed in cardiac surgical patients when CVP was

The effects of levosimendan in cardiac surgery patients with poor left ventricular function.

BACKGROUND: Patients with poor left ventricular function often require inotropic drug support immediately after cardiopulmonary bypass. Levosimendan improves cardiac function by a novel mechanism of action compared to currently available drugs. We hypothesized that, in patients with severely compromised ventricular function, the use of levosimendan would be associated with better postoperative cardiac function than with inotropic drugs that increase myocardial oxygen consumption. METHODS: Thirty patients with a preoperative ejection fraction < or =30% scheduled for elective cardiac surgery with cardiopulmonary bypass were randomized to two different inotropic protocols: milrinone 0.5 microg [corrected] x kg(-1) x min(-1) or levosimendan 0.1 microg [corrected] x kg(-1) x min(-1), started immediately after the release of the aortic crossclamp. The treatment was masked to the observers. All patients received dobutamine 5 microg [corrected] x kg(-1) x min(-1). RESULTS: Stroke volume was similar between groups initially after surgery, but it declined 12 h after surgery in the milrinone group but not in the levosimendan group (P < 0.05 between groups) despite similar filling pressures. Total dose, duration of inotropic drug administration and norepinephrine dose were lower in the levosimendan group than in the milrinone group (P < 0.05). The duration of tracheal intubation was shorter in the former group compared with the milrinone group (P = 0008). Three patients in the milrinone group but none in the levosimendan group died within 30 days of surgery. CONCLUSION: In cardiac surgery patients with a low preoperative ejection fraction, stroke volume was better maintained with the combination of dobutamine with levosimendan than with the combination of dobutamine with milrinone.

Effects of sevoflurane on biomechanical markers of hepatic and renal dysfunction after coronary artery surgery.

OBJECTIVE: The purpose of this study was to compare the effects of a total intravenous and a volatile anesthetic regimen on biochemical markers of hepatic and renal dysfunction after coronary artery surgery. DESIGN: Prospective, double-blind, randomized clinical study. SETTING: University hospital, single institutional. PARTICIPANTS: Three hundred twenty patients undergoing elective coronary artery surgery were divided into 2 different anesthetic protocols: propofol group (n = 160) and sevoflurane group (n = 160). INTERVENTIONS: Hemodynamic data were registered before the start of surgery, before the start of CPB, 15 minutes after the end of CPB, at arrival in the intensive care unit, and 6 and 12 hours after arrival in the intensive care unit. Serum glutamic oxaloacetic transaminase (SGOT), serum glutamate pyruvate transaminase (SGPT), serum lactate dehydrogenase (LDH), and serum creatinine concentrations were measured before surgery, at arrival in the intensive care unit, and after 6, 12, 24, and 48 hours. MEASUREMENTS AND MAIN RESULTS: Postoperative levels of serum SGOT, SGPT, and LDH increased transiently in both anesthetic groups, but the increase was significantly lower in the sevoflurane group compared with the propofol group. Creatinine levels remained largely unchanged in both groups. CONCLUSION: Postoperative biochemical markers of hepatic dysfunction were lower with a sevoflurane-based anesthetic regimen in patients undergoing coronary artery surgery with cardiopulmonary bypass.

Cerebral electrical activity as a tool in evaluating anesthetic effect during balanced anesthesia with sevoflurane.

OBJECTIVES: The present study was undertaken to provide basic information about bilateral frontal cerebral electrical activity after induction, before and after skin incision, and at a steady state during sevoflurane anesthesia at the end tidal concentration 1, 1.2, 1.4 and 1.6 MAC and determine the association between the electrical cerebral activity with other clinical end points, i.e. motor responses and post-operative recall. MATERIAL AND METHOD: the Dual Channel Brain Activity, ABM2 (DATEX) was used to continuously monitor frontal EMG and electrical cerebral activities (i.e. frequency and amplitude) of both hemispheres in 20 adult female patients undergoing balanced anesthesia in Maharaj Chiang Mai Hospital. The eligible patients were randomly assigned to receive 1.0 MAC, 1.2MAC, 1.4MAC or 1.6MAC of a mixture of sevoflurane and 66.67% nitrous oxide in oxygen during anesthesia. The anesthesia was induced with 5 mg/kg thiopental and supplemented with 1-1.5 microgram per kilogram of fentanyl. The standard dose of pancuronium or atracurium was given during maintenance. RESULTS: After induction with 5 mg/kg thiopental, the mean (95% confidence interval) of frontal EMG significantly decreased from 2.66 (1.63,4.29) to 1.41 (0.2,1.61). When eyelash reflex was absent, the mean (95%CI) frequency and amplitude of the right frontal EEG was 3.89 (3.29, 4.497) Hz, 39.58 (32.11, 47.05) microvolt and left frontal EEG was 3.84 (3.43, 4.25) Hz, 33.55 (28.59, 38.61) microvolt. The findings were consistent with the raw EEG shown on the monitor, i.e. a progressive decrease in the frequency and an increase in the amplitude. During maintenance with the inhaled anesthetics, there was a statistically significant decrease in frequency of right frontal in those who had received the inhaled anesthetic concentration to reach 1.4 and 1.65 MAC (p < 0.05) (repeated measure ANOVA). At the steady state of end tidal concentration of the sevoflurane there was consistency in decreasing frequencies and increasing amplitudes of both hemispheres of the groups with higher MAC values (p < 0.05) (Table 3). However, the authors failed to demonstrate the relationships between EEG changes and other clinical responses. CONCLUSION: The present study has provided basic information about cerebral electrical activity during the balanced anesthesia with sevoflurane. As anesthesia deepened by increased MAC, the frequency decreased and the amplitude increased.