Goal directed preemptive ephedrine attenuates the reperfusion syndrome during adult living donor liver transplantation

Background: End-stage liver disease is associated with marked hemodynamic disturbances that are further deteriorated during liver transplantation and is aggressively represented in the form of postreperfusion syndrome (PRS). Aim: The aim was to test the hypothesis that preemptive ephedrine administration pre-reperfusion targeting a rational level of mean arterial blood pressure (MAP) of 85–100 mmHg, may reduce the incidence of PRS. Patient and methods: One hundred recipients for adult living donor liver transplantation (ALDLT) were prospectively randomized into 2 groups; group C, control group and group E, who received ephedrine 2.5–5 mg/min starting 5 min before reperfusion till mean arterial blood pressure (MAP) reached 85–100 mmHg. Hemodynamic parameters including MAP, heart rate (HR), Transesophageal Doppler (TED) parameters including corrected flow time (FTc), systemic vascular resistance (SVR), and cardiac output (COP) were measured; just predrug administration, just before reperfusion, just after reperfusion, 5 min after reperfusion and at the end of surgery. Cold and warm ischemia times (C/WIT), duration of anhepatic phase and total duration of surgery were recorded. The incidence of PRS, the need of rescue vasoconstrictor for hemodynamic instability at time of reperfusion, need for postreperfusion vasoconstrictor infusions, over shooting of hemodynamics, postreperfusion fibrinolysis indicated by fibrinogen level and maximum lysis parameter of rotational thromboelastometry (ROTEM) were compared between both groups. Results: The mean dose of ephedrine required was (12.5 ± 7.5 mg). Group E had statistically significant increase in MAP, SVR, and COP; just before reperfusion, just after reperfusion and 5 min after reperfusion readings. There were no statistical significant differences between the 2 groups at the end of surgery. The incidence of PRS and the need of rescue adrenaline at the time of reperfusion, and the postreperfusion need for vasoconstrictor infusion decreased significantly in group E when compared to group C. Also postoperative mechanical ventilation decreased significantly in group E. Conclusion: The preemptive goal directed titration of ephedrine against a target MAP pre-reperfusion could decrease the incidence of PRS by 40%, attenuated the hypotensive response to reperfusion and decreased the need for postreperfusion vasoconstrictor support without over shooting of any of the monitored hemodynamic indices

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). 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 H 2 O. TED fluid management protocols during resection need to be developed

Live donor hepatectomy for liver transplantation in Egypt: Lessons learned

Purpose: To retrospectively review anesthesia and intensive care management of 145 consented volunteers subjected to right lobe or left hepatectomy between 2003 and 2011. Methods: After local ethics committee approval, anesthetic and intensive care charts, blood transfusion requirements, laboratory data, complications and outcome of donors were analyzed. Results: One hundred and forty-three volunteers successfully tolerated the surgery with no blood transfusion requirements, but with a morbidity rate of (50.1%). The most frequent complication was infection (21.1%) (intraabdominal collections), followed by biliary leak (18.2%). Two donors had major complications: one had portal vein thrombosis (PVT) treated with vascular stent. This patient recovered fully. The other donor had serious intraoperative bleeding and developed postoperative PVT and liver and renal failure. He died after 12 days despite intensive treatment. He was later reported among a series of fatalities from other centers worldwide. Epidural analgesia was delivered safely (n=90) with no epidural hematoma despite significantly elevated prothrombin time (PT) and international normalization ratio (INR) postoperatively, reaching the maximum on Day 1 (16.9±2.5 s and 1.4±0.2, P<0.05 when compared with baseline). Hypophosphatemia and hypomagnesemia were frequently encountered. Total Mg and phosphorus blood levels declined significantly to 1.05±0.18 mg/dL on Day 1 and 2.3±0.83 mg/dL on Day 3 postoperatively. Conclusions: Coagulation and electrolytes need to be monitored perioperatively and replaced adequately. PT and INR monitoring postoperatively is still necessary for best timing of epidural catheter removal. Live donor hepatectomy could be performed without blood transfusion. Bile leak and associated infection of abdominal collections requires further effort to better identify biliary leaks and modify the surgical closure of the bile ducts. Donor hepatectomy is definitely not a complication-free procedure; reported complication risks should be available to the volunteers during consenting