Abstract:Aims:To report the use of transesophageal Doppler (TED), a minimally invasive cardiac output (COP) monitor, before, during and after reperfusion and study its effect on anesthetic management during living donor liver transplantation (LDLT).Setting and Design:A prospective observational study.Methods:A total of 25 consecutive recipients with a MELD score between 15 and 20 were enrolled. Data were recorded at baseline (TB); anhepatic phase (TA); and post-reperfusion — 1, 5, 10 and 30 minutes. Fluid therapy was g… Show more
“…Terlipressin was previously suggested to have a beneficial effect on haemodynamics and related peri-operative outcome in LDLT,[ 4 8 ] but few studies monitored these haemodynamic changes with TOD during the procedure. [ 2 ] The results of this study demonstrated that with terlipressin, the TOD calculated SVR was significantly better preserved during the a hepatic phase and immediately after reperfusion compared to controls. This was reflected in a better mean arterial BP without any significant reduction in COP and heart rate during the immediate post-operative period as seen in a study by Mukhtar et al .…”
Section: Discussionmentioning
confidence: 76%
“…Impaired hepatic clearance in the patients with end stage liver disease often causes the levels of endogenous vasodilators to increase. [ 1 2 ] This results in a decline in systemic vascular resistance (SVR) and redistribution of the body fluids from the central to the peripheral compartment, reducing effective blood flow to organs as the kidneys. [ 3 ]…”
Background and Aims:Liver disease is usually accompanied with a decline in systemic vascular resistance (SVR). We decided to assess effects of the peri-operative terlipressin infusion on liver donor liver transplantation recipients with respect to haemodynamics and renal parameters.Methods:After Ethical Committee approval for this prospective randomised controlled study, 50 recipients were enrolled and allotted to control (n = 25) or terlipressin group (n = 25) with simple randomisation method. Terlipressin was infused at 1.0 μg/kg/h and later titrated 1.0–4.0 μg/kg/h to maintain mean arterial pressure (MAP) >65 mmHg and SVR index <2600 dyne.s/cm5/ m2 till day 4. Nor-epinephrine was used as appropriate. Haemodynamic and transoesophageal Doppler parameters (intraoperative), renal function, peak portal vein blood flow velocity (PPV), hepatic artery resistive index (HARI), urine output (UOP), liver enzymes, catecholamine support were compared intra-operatively and 4 days post-operatively. Desflurane administration was guided with entropy.Results:Terlipressin maintained better MAP and SVR (P < 0.01) during reperfusion versus controls (66.5 ± 16.08 vs. 47.7 ± 4.7 mmHg and 687.7 ± 189.7 vs. 425.0 ± 26.0 dyn.s/cm5), respectively. Nor epinephrine was used in 5 out of 25 versus 20 in controls. Urea, creatinine and UOP were significantly better with terlipressin. PPV was reduced with terlipressin post-reperfusion versus controls (44.8 ± 5.2 vs. 53.8 ± 3.9 ml/s, respectively, P < 0.01) without affecting HARI (0.63 ± 0.06 vs. 0.64 ± 0.05, respectively, P > 0.05) and was sustained post-operatively.Conclusion:Terlipressin improved SVR and MAP with less need for catecholamines particularly post-reperfusion. Terlipressin reduced PPV without hepatic artery vasoconstriction and improved post-operative UOP.
“…Terlipressin was previously suggested to have a beneficial effect on haemodynamics and related peri-operative outcome in LDLT,[ 4 8 ] but few studies monitored these haemodynamic changes with TOD during the procedure. [ 2 ] The results of this study demonstrated that with terlipressin, the TOD calculated SVR was significantly better preserved during the a hepatic phase and immediately after reperfusion compared to controls. This was reflected in a better mean arterial BP without any significant reduction in COP and heart rate during the immediate post-operative period as seen in a study by Mukhtar et al .…”
Section: Discussionmentioning
confidence: 76%
“…Impaired hepatic clearance in the patients with end stage liver disease often causes the levels of endogenous vasodilators to increase. [ 1 2 ] This results in a decline in systemic vascular resistance (SVR) and redistribution of the body fluids from the central to the peripheral compartment, reducing effective blood flow to organs as the kidneys. [ 3 ]…”
Background and Aims:Liver disease is usually accompanied with a decline in systemic vascular resistance (SVR). We decided to assess effects of the peri-operative terlipressin infusion on liver donor liver transplantation recipients with respect to haemodynamics and renal parameters.Methods:After Ethical Committee approval for this prospective randomised controlled study, 50 recipients were enrolled and allotted to control (n = 25) or terlipressin group (n = 25) with simple randomisation method. Terlipressin was infused at 1.0 μg/kg/h and later titrated 1.0–4.0 μg/kg/h to maintain mean arterial pressure (MAP) >65 mmHg and SVR index <2600 dyne.s/cm5/ m2 till day 4. Nor-epinephrine was used as appropriate. Haemodynamic and transoesophageal Doppler parameters (intraoperative), renal function, peak portal vein blood flow velocity (PPV), hepatic artery resistive index (HARI), urine output (UOP), liver enzymes, catecholamine support were compared intra-operatively and 4 days post-operatively. Desflurane administration was guided with entropy.Results:Terlipressin maintained better MAP and SVR (P < 0.01) during reperfusion versus controls (66.5 ± 16.08 vs. 47.7 ± 4.7 mmHg and 687.7 ± 189.7 vs. 425.0 ± 26.0 dyn.s/cm5), respectively. Nor epinephrine was used in 5 out of 25 versus 20 in controls. Urea, creatinine and UOP were significantly better with terlipressin. PPV was reduced with terlipressin post-reperfusion versus controls (44.8 ± 5.2 vs. 53.8 ± 3.9 ml/s, respectively, P < 0.01) without affecting HARI (0.63 ± 0.06 vs. 0.64 ± 0.05, respectively, P > 0.05) and was sustained post-operatively.Conclusion:Terlipressin improved SVR and MAP with less need for catecholamines particularly post-reperfusion. Terlipressin reduced PPV without hepatic artery vasoconstriction and improved post-operative UOP.
“…The data of the limited studies in which the amount of urine output was reported are collected in Additional file 1 : Table S4. The data on the six observational studies [ 60 – 65 ] are reported in Additional file 1 : Table S5 and Table S6. Fig.…”
BackgroundOliguria is associated with a decreased kidney- and organ perfusion, leading to organ damage and increased mortality. While the effects of correcting oliguria on renal outcome have been investigated frequently, whether urine output is a modifiable risk factor for mortality or simply an epiphenomenon remains unclear. We investigated whether targeting urine output, defined as achieving and maintaining urine output above a predefined threshold, in hemodynamic management protocols affects 30-day mortality in perioperative and critical care.MethodsWe performed a systematic review with a random-effects meta-analyses and meta-regression based on search strategy through MEDLINE, EMBASE and references in relevant articles. We included studies comparing conventional fluid management with goal-directed therapy and reporting whether urine output was used as target or not, and reporting 30-day mortality data in perioperative and critical care.ResultsWe found 36 studies in which goal-directed therapy reduced 30-day mortality (OR 0.825; 95% CI 0.684-0.995; P = 0.045). Targeting urine output within goal-directed therapy increased 30-day mortality (OR 2.66; 95% CI 1.06-6.67; P = 0.037), but not in conventional fluid management (OR 1.77; 95% CI 0.59-5.34; P = 0.305). After adjusting for operative setting, hemodynamic monitoring device, underlying etiology, use of vasoactive medication and year of publication, we found insufficient evidence to associate targeting urine output with a change in 30-day mortality (goal-directed therapy: OR 1.17; 95% CI 0.54-2.56; P = 0.685; conventional fluid management: OR 0.74; 95% CI 0.39-1.38; P = 0.334).ConclusionsThe principal finding of this meta-analysis is that after adjusting for confounders, there is insufficient evidence to associate targeting urine output with an effect on 30-day mortality. The paucity of direct data illustrates the need for further research on whether permissive oliguria should be a key component of fluid management protocols.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-017-0316-4) contains supplementary material, which is available to authorized users.
“…Our team hypothesized that there would be a trend toward increasing use of CO monitoring devices in the operating room by the anesthesiologist, specifically with a preference toward transesophageal echocardiography (TEE). [456]…”
Background:
Electronic monitoring of physiologic variables has gained widespread support over the past decade for critical patients in the intensive care setting. Specifically, anesthesiologists have increased the emphasis and practice of hemodynamic control through monitoring cardiac output (CO). However, these physicians are presented with several options in terms of how they wish to study the trend of this physiologic parameter.
Materials and Methods:
A survey was distributed to 250 general and subspecialty-trained anesthesiologists. A series of questions were presented in terms of preference of patient monitoring methods requiring yes or no answers. Anesthesiologists were asked about subspecialty training, years since residency graduation, and preferences toward specific hemodynamic monitoring tools. Nonparametric statistical analysis and Chi-squared tests were used to analyze both normal and nonnormally distributed data.
Results:
CO monitoring devices were implemented by 106 out of 133 anesthesiologists, with 98 of these physicians utilizing CO monitoring for fluid and vasopressors response. Of the physicians implementing a monitoring device, 48 out of 107 physicians preferred pulmonary artery catheter, while pulse contour analysis was preferred by 17 anesthesiologists. An echocardiography unit was available to the department for 90 anesthesiologists, and 77 anesthesiologists were trained to use this technology for monitoring cardiac function.
Conclusion:
Many anesthesiologists have placed emphasis on the importance of CO monitoring within the intensive care setting. However, physicians are still faced with multiple options in terms of how they wish to specifically monitor this hemodynamic variable. Factors that influence such decisions include the time of physician's residency training along with patient and clinical case characteristics.
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