The effect of low central venous pressure on hepatic surgical field bleeding and serum lactate in patients undergoing partial hepatectomy: a prospective randomized controlled trial

Abstract

Background: This prospective randomized controlled study was designed to evaluate the effect of fluid restriction alone versus fluid restriction + low central venous pressure (CVP) on hepatic surgical field bleeding, intraoperative blood loss, and the serum lactate concentration in patients undergoing partial hepatectomy. Methods: One hundred forty patients undergoing partial hepatectomy with intraoperative portal triad clamping were randomized into a fluid restriction group (Group F) or fluid restriction + low CVP group (Group L). Both groups received limited fluid infusion before the liver lesions were removed. Ephedrine was administered if the systolic blood pressure (SBP) decreased to <90 mmHg for 1 min. When the urine output was <20 ml/h or the SBP was <90 mmHg for 1 min more than three times, an additional 200 ml of crystalline solution was quickly infused within 10 min. In addition to fluid restriction, patients in Group L received continuous nitroglycerin and esmolol infusion to maintain a low CVP. The duration of portal triad clamping, frequency of additional fluid infusion, frequency of ephedrine administration, intraoperative blood loss, extent of liver resection, and bleeding score of the hepatic surgical field were recorded. Arterial blood gas analysis was performed before anesthesia (T1), after liver dissection and immediately before liver resection (T2), 10 min after removal of the liver lesion (T3), and before the patient was discharged from the postanesthesia care unit (T4).Results: Being in the fluid restriction Group (Group F) (odds ratio = 5.04) and cirrhosis (odds ratio = 3.28) were risk factors for hepatic surgical field bleeding. Factors contributing to intraoperative blood loss were the operation time, duration of portal triad clamping, and extent of resection. No significant between-group difference was observed for blood loss or blood transfusion. The serum lactate concentration peaked at T3 in both groups. Conclusions: Maintaining a lower CVP during hepatectomy provides an optimal surgical field but has no significant effect on intraoperative blood loss. Moreover, lower CVP does not increase the serum lactate concentration. Trial registration: "A comparative study of the effect fluid restriction and low CVP pressure on the oozing of blood in liver wounds and blood lactate in patients undergoing partial hepatectomy" was prospectively registered as a trial (registration number: ChiCTR-INR-17014172, date of registration: 27 December 2017).

Efficacy and safety of infrahepatic inferior vena cava clamping under controlled central venous pressure for reducing blood loss during hepatectomy: A randomized controlled trial

“…However, some previous studies have raised concerns about the safety of IVC clamping, especially the risk of pulmonary embolism and acute kidney injury 17,20,24 . Moreover, the latest prospective randomized controlled trial revealed that IVC clamping has no effect on intraoperative blood loss 25 . Thus, our goal was to resolve this controversy.…”

“…17,20,24 Moreover, the latest prospective randomized controlled trial revealed that IVC clamping has no effect on intraoperative blood loss. 25 Thus, our goal was to resolve this controversy.…”

Is the Pringle manoeuvre becoming a lost art? Contemporary use for both severe liver trauma with ongoing hemorrhage and elective partial hepatectomy

“… 2 , 7 In elective hepatectomy, this coincides with the transition to new energy instrumentation for parenchymal dissection/transection, 8 as well as dedication to low central venous pressure anesthesia. 6 More specifically, Pringle occlusion in our elective hepatectomies performed during the past decade was 6.0% and reserved for scenarios to control “unwanted” hemorrhage (i.e., not to pre-empt bleeding). Interestingly, only 2.1% of patients received a Pringle manoeuvre within the past 5 years (v. 21.2% in the 5 years before the study period).…”

“… 2 , 3 In cases of elective hepatic resection, the Pringle manoeuvre has classically been engaged to either prevent ongoing bleeding during parenchymal transection, or as a response to brisk hemorrhage during the resection. 4 Interestingly, with the widespread use of both novel energy devices 5 and low central venous pressure anesthesia, 6 the requirement for Pringle manoeuvre engagement has seemingly decreased over time. In an attempt to reflect on this evolution, we evaluated the Pringle manoeuvre over a period of 10 years (2010–2020) in both HPB and trauma surgeries.…”

Influence of obesity and fluid restriction on operative outcomes in hepatic resection

“…Changes in the patient's body position, such as the head-up tilt position, signi cantly decrease CVP but not hepatic vein pressure (Sand L et al, 2011). Diuretics or vasodilators can be administered to decrease CVP, but their effectiveness is limited because these drugs require duration for action, and the liver receives a large amount of blood from the portal vein (Yu L et al, 2020).…”