Hemodynamic and Metabolic Changes in Hepatic Transplantation (original) (raw)
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Hemodynamic Changes and Early Recovery of Liver Graft Function after Liver Transplantation
2020
Background Patients with liver cirrhosis experience a hyperdynamic circulation. Objective To investigate the association between early hemodynamic changes and graft function after liver transplant. Methods Those patients who underwent liver transplantation in 2016 were enrolled in the study. Liver function indices measured in postoperative days (POD) 1, 3, 5, 7, 9, and 11 along with hemodynamic indices including pulse rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), and central venous pressure (CVP) measured q6h in the first 3 days after transplantation were recorded. Results 57 deceased-donor liver recipients with a mean±SD age of 41.4±11.8 years including 33 (58%) males were enrolled in the study. The mean±SD aspartate and alanine aminotransferases, alkaline phosphatase, and lactate dehydrogenase were significantly decreased from 1879±670.5, 369.2±40.5, 174.9±18.8, and 1907.6±323.1 U/L in POD 1 to 37.2±10.7, 243.4±37.3, 207.5±19.5, and 382.4±59.8 U/L in POD 3, ...
The interaction of systemic hemodynamics with hepatic flows at the time of liver transplantation (LT) has not been studied in a prospective uniform way for different types of grafts. We prospectively evaluated intraoperative hemodynamics of 103 whole and partial LT. Liver graft hemodynamics were measured using the ultrasound transit time method to obtain portal (PVF) and arterial (HAF) hepatic flow. Measurements were recorded on the native liver, the portocaval shunt, following reperfusion and after biliary anastomosis. After LT HAF and PVF do not immediately return to normal values. Increased PVF was observed after graft implantation. Living donor LT showed the highest compliance to portal hyperperfusion. The amount of liver perfusion seemed to be related to the quality of the graft. A positive correlation for HAF, PVF and total hepatic blood flow with cardiac output was found (p = 0.001). Portal hypertension, macrosteatosis >30%, warm ischemia time and cardiac output, independently influence the hepatic flows. These results highlight the role of systemic hemodynamic management in LT to optimize hepatic perfusion, particularly in LDLT and split LT, where the highest flows were registered.
Hemodynamics During Liver Transplantation
Transplantation Proceedings, 2007
Assessing the optimal volemia in the perioperative course of liver transplantation is a challenge for the anesthesiologist. Traditional estimates of intravascular volume status, such as pulmonary artery occlusion pressure (PAOP), have been widely shown to poorly correlate with changes in cardiac output among critically ill patients. Hence, there has been recent interest in alternative, catheter-related, bedside device volume estimates using thermodilution. Continuous end diastolic volume (CEDVI) showed better correlations with cardiac performance than cardiac filling pressures in studies performed in critically ill patients. When compared with conventional pressure-derived data, preload monitoring estimated as intrathoracic blood volume index (ITBVI) with the PiCCO system based on an integrated transpulmonary thermodilution technique better reflected left ventricular filling both in critically ill patients and those who underwent liver transplantation. Moreover, in liver transplantation, the use of transoesophageal echocardiography (TEE) has been increasing for it provides rapid visualization of the dimension and function of heart chambers as well as the left ventricular end diastolic area index (EDAI) that seem to correlate with graded acute hypovolemia, although its validity as on preload index is still under discussion.
Intraoperative blood loss in orthotopic liver transplantation: The predictive factors
World journal of gastrointestinal surgery, 2015
Liver transplantation has been associated with massive blood loss and considerable transfusion requirements. Bleeding in orthotopic liver transplantation is multifactorial. Technical difficulties inherent to this complex surgical procedure and pre operative derangements of the primary and secondary coagulation system are thought to be the principal causes of perioperative hemorrhage. Intraoperative practices such as massive fluid resuscitation and resulting hypothermia and hypocalcemia secondary to citrate toxicity further aggravate the preexisting coagulopathy and worsen the perioperative bleeding. Excessive blood loss and transfusion during orthotopic liver transplant are correlated with diminished graft survival and increased septic episodes and prolonged ICU stay. With improvements in surgical skills, anesthetic technique, graft preservation, use of intraoperative cell savers and overall perioperative management, orthotopic liver transplant is now associated with decreased intra...
JAMA Surgery, 2015
IMPORTANCE Damage control (DC) with intra-abdominal packing and delayed reconstruction is an accepted strategy in trauma and acute care surgery but has not been evaluated in liver transplant. OBJECTIVE To evaluate the incidence, effect on survival, and predictors of the need for DC using intra-abdominal packing and delayed biliary reconstruction in patients with coagulopathy or hemodynamic instability after liver allograft reperfusion. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective analysis of adults undergoing liver transplant at a large transplant center from February 1, 2002, through July 31, 2012. MAIN OUTCOMES AND MEASURES Predictors of DC, effects on graft, and patient survival. RESULTS Of 1813 patients, 150 (8.3%) underwent DC during liver transplant, with 84 (56.0%) requiring a single additional operation for biliary reconstruction and abdominal closure and 57 (38.0%) requiring multiple additional operations. Compared with recipients without DC, patients requiring DC had greater Model for End-stage Liver Disease scores (33 vs 27; P < .001); more frequent pretransplant hospitalization (72.0% vs 47.9%; P < .001), intubation (33.3% vs 19.9%; P < .001), vasopressors (23.2% vs 10.9%; P < .001), renal replacement therapy (49.6% vs 30.3%; P < .001), and prior major abdominal operations (48.3% vs 21.9%; P < .001), including prior liver transplant (29.3% vs 8.9%; P < .001); greater operative transfusion requirements (37 vs 13 units of packed red blood cells; P < .001); worse intraoperative base deficit (10.3 vs 8.4; P = .03); more frequent postreperfusion syndrome (56.2% vs 27.3%; P < .001); and longer cold (430 vs 404 minutes; P = .04) and warm (46 vs 41 minutes; P < .001) ischemia times. Patients who underwent DC followed by a single additional operation for biliary reconstruction and abdominal closure had similar 1-, 3-, and 5-year graft survival (71%, 62%, and 62% vs 81%, 71%, and 67%; P = .26) and patient survival (72%, 64%, and 64% vs 84%, 75%, and 70%; P = .15) compared with recipients not requiring DC. Multivariate predictors of DC included prior liver transplant or major abdominal operation, longer pretransplant recipient and donor length of stay, greater Model for End-stage Liver Disease score, and longer warm and cold ischemia times (C statistic, 0.75). CONCLUSIONS AND RELEVANCE To our knowledge, this study represents the first large report of DC as a viable strategy for liver transplant recipients with coagulopathy or hemodynamic instability after allograft reperfusion. In DC recipients not requiring additional operations, outcomes are excellent and comparable to 1-stage liver transplant.
Transplantation, 2006
Introduction. Our previous studies showed correlation of intra-operative renal allograft blood flow and its immediate function. Similar relation in liver transplantation is not well established. Aim. The aim of this study was to assess the relation in between hepatic blood flow on revascularization of the liver allograft and its immediate function. Methods. Hepatic artery and portal vein blood flow were assessed in 37 liver transplant-recipients with Transonic HT207 Volume Flowmeter. Additionally, parenchymal flow was recorded with laser Doppler. Measurements were taken at 30 and 120 minutes after simultaneous arterial/ portal reperfusion. Flow results were correlated to early liver function. Results. Mean arterial blood flow (ABF) was 17,1 to 15,4ml/min/100g and has not changed between 30 and 120 minutes. Portal flow (PF) decreased from 150 at 30 min. to 123 ml/min/100g at 120 min. Parenchymal flow did not alter over the time (18 and 16,3 ml/min/100g, respectively). Significant correlation of PF with early graft function parameters such as: serum AST [R=-0,33 p<0.05] and ALT level [R=-0,42 p<0.05] assayed daily for 14 days. Similar observations were made between ABF and INR [R=-0,49 p<0,05], bilirubin level [R=-0.42 p<0.05], parenchymal flow and ALT [R=-0,37 p<0.05]. Mean PF was 133 ml/min/100g (SD= 56) in group with early good liver function vs. 71 ml/min/100g (SD= 38) in slow liver function group was statistically different p<0.05. Similar observations were made in mean ABF. Conclusions. These preliminary results suggest hepatic blood flow to be reliable predictor of graft viability and function. Of the variables measured, portal blood flow seems to be the most valuable indicator of liver function.