The predictive performance of infusion strategy nomogram based on a fluid kinetic model / 대한마취과학회지

BACKGROUND: In a previous study, fluid kinetic models were applied to describe the volume expansion of the fluid space by administration of crystalloid and colloid solutions. However, validation of the models were not performed, it is necessary to evaluate the predictive performance of these models in another population. METHODS: Ninety five consenting patients undergoing elective spinal surgery under general anesthesia were enrolled in this study. These patients were randomly assigned to three fluid groups i.e. Hartmann's solution (H group, n = 28), Voluven(R) (V group, n = 34), and Hextend(R) (X group, n = 33). After completion of their preparation for surgery, the patients received a loading and maintenance volume of each fluid predetermined by nomograms based on fluid pharmacokinetic models during the 60-minute use of an infusion pump. Arterial samples were obtained at preset intervals of 0, 10, 20, and 30 min after fluid administration. The predictive performances of the fluid kinetic modes were evaluated using the fractional change of arterial hemoglobin. The relationship between blood-volume dilution and target dilution of body fluid space was also evaluated using regression analysis. RESULTS: A total of 194 hemoglobin measurements were used. The bias and inaccuracy of these models were -2.69 and 35.62 for the H group, -1.53 and 43.21 for the V group, and 9.05 and 41.82 for the X group, respectively. The blood-volume dilution and target dilution of body-fluid space showed a significant linear relationship in each group (P < 0.05). CONCLUSIONS: Based on the inaccuracy of predictive performance, the fluid-kinetic model for Hartmann's solution showed better performance than the other models.

Comparison of intermittent versus continuous interscalene brachial plexus block for postoperative analgesia

BACKGROUND: Interscalene brachial plexus block (IBPB) is an effective method of postoperative analgesia after shoulder surgery. This study evaluates the effects and complications of IBPB with two different infusion methods (using intermittent bolus infusion versus automated continuous infusion). METHODS: Thirty six patients who were scheduled for shoulder surgery were randomly assigned into two groups (the continuous vs. intermittent groups). All the patients received preoperative IBPB using 15 ml of 0.25% ropivacaine followed by insertion of a 20 gauge catheter. This catheter was connected to a patient controlled analgesia (PCA) pump after the operation. The intermittent group (n = 18) received IBPB with 0.2% ropivacaine 100 ml (bolus 15 ml, lock time 4 h) without basal infusion. The continuous group (n = 18) received IBPB with 0.2% ropivacaine 100 ml (basal rate 4 ml/h) without bolus injection. All the patients were given meperidine 25 mg when the postoperative visual analogue score (VAS) >40 mm. The VAS, heart rate, noninvasive blood pressure, respiratory rate, consumption of meperidine and complications were measured during the 64 h following surgery at intervals of 8 h. RESULTS: The VAS was higher in the intermittent group than that in the continuous group at 24 h after surgery (P < 0.01).However, there was no significant difference for the VAS between the groups for the other assessment periods.There was no significant difference for the amount of meperidine consumed and the incidence of complications between the groups. CONCLUSIONS: Intermittent IBPB's analgesic effects and complications for treating pain after shoulder surgery are similar to those of continuous IBPB. Therefore, intermittent IBPB could be used for the management of pain after shoulder surgery.

Comparing the effects of thiopental and propofol administration on the cardiovascular response as an induction agent during desflurane anesthesia

BACKGROUND: This study was undertaken to compare the hemodynamic effects of thiopental and propofol administration as induction agents during desflurane anesthesia. METHODS: One hundred twenty unpremedicated ASA physical status 1 patients who were aged 20-60 years and who scheduled for elective surgery under general anesthesia were randomly divided into two groups. In group T, thiopental sodium (5 mg/kg) was used to induce anesthesia, whereas propofol (2.5 mg/kg) was used in group P. In each group, the inspired concentration of desflurane was increased to 4.0 vol% shortly after a thiopental or propofol injection. After 10 manual baggings, the target was increased to produce an end-tidal concentration of desflurane (ETdesf) of 8.0 vol%, and this was maintained until the end of the study by adjusting the vaporizer setting. The heart rate (HR) and mean arterial pressure (MAP) were measured at baseline, 2 min and 5 min after induction and at 2 min after intubation. RESULTS: The heart rate was significantly increased in the two groups compared with baseline. In the P group, the mean blood pressure was decreased at 2 and 5 min after induction compared with baseline, whereas the mean blood pressure in the T group was significantly increased after induction. The mean blood pressure was significantly lower in group P than that in group T at 2 and 5 min after the injection of the induction agent. However, the heart rate did not differ significantly between two groups. CONCLUSIONS: During desflurane anesthesia, the heart rate did not differ significantly between the two groups, yet the mean blood pressure was significantly lower when using propofol than that when using thiopental sodium.

Effects of anesthesia on fluid volume kinetics after infusion of colloid solution during blood donation / 대한마취과학회지

BACKGROUND: The fluid kinetics of intravenously infused colloid during inhalation anesthesia and hemorrhage have not been investigated. We therefore assessed fluid space changes during infusion of hydroxyethyl starch solution after hemorrhage in conscious and desflurane-anesthetized individuals. METHODS: Following the donation of 400 ml of blood, 500 ml of hydroxyethyl starch solution was infused over 20 minutes into wakeful and desflurane-anesthetized volunteers. Blood was repeatedly sampled to measure hemoglobin concentration, a marker of plasma dilution, and fluid kinetic analysis was performed to evaluate changes in fluid space. RESULTS: Using a fluid kinetic model, we found that the mean volume of fluid space was 7,724 +/- 1,788 ml in wakeful volunteers and 6,818 +/- 4,221 ml in anesthetized volunteers, and the elimination rate constants were 7.1 +/- 3.5 ml/min and 19.4 +/- 4.6 ml/min, respectively. CONCLUSIONS: Infusion of colloid after mild hemorrhage resulted in similar expansions of plasma volume in desflurane-anesthetized and conscious individuals. During anesthesia, however, the expansion of plasma volume by colloid was decreased and of shorter duration than observed in conscious patients.

The effects of inspiratory to expiratory ratio on ventilation and oxygenation during high frequency partial liquid ventilation in a rabbit model of acute lung injury / 대한마취과학회지

BACKGROUND: We examined the effects of varying inspiratory to expiratory (I : E) ratio on gas exchange and hemodynamics during high frequency partial liquid ventilation (HFPLV), a combination of high frequency ventilation (HFV) and partial liquid ventilation (PLV), in a rabbit model of acute lung injury. METHODS: Twelve rabbits treated with repeated saline lavage were divided into two groups. In the HFPL group (n = 6), 6 ml/kg of perfluorodecaline was administered through the endotracheal tube. Rabbits in this group and in the HFJ group (n = 6) were treated with high frequency jet ventilation (HFJV) at I : E ratios of 1 : 1, 1 : 2, and 1 : 3 for 15 minutes, and arterial blood gas, mixed venous blood gas and hemodynamic parameters were measured. RESULTS: We observed no significant respiratory and hemodynamic differences between the two groups. At an I : E ratio of 1 : 1, the PaO2 was significantly higher, and the shunt rate and PaCO2 were significantly lower in both groups, compared with I : E ratios of 1 : 2 and 1 : 3. Cardiac output at the 1 : 3 I : E ratio was significantly higher than at 1 : 1. CONCLUSIONS: These findings indicate that, in this model, a 1 : 1 I : E ratio was superior for oxygenation and ventilation than I : E ratios of 1 : 2 or 1 : 3, while having no detrimental effects on hemodynamics.

Anesthetic management of a child with Apert syndrome : A case report

Apert syndrome involves abnormal growth of several bones such as craniofacial abnormalities, craniosynostosis and syndactyly of the feet and hands. Apert syndrome often demonstrates to the operating room for craniofacial and extremity operations. Previous reports reveal that children with Apert syndrome suffered difficulties in mask ventilation and difficult airway management during anesthetic management.We report our experience with anesthesia of a 26-month-old female patient with Apert syndrome who underwent syndactyly for separation.

Assessment of Fluid Space after Infusion of Hartmann's Solution and Hydroxethyl Starch Solutions during General Anesthesia / 대한마취과학회지

BACKGROUND: Distribution and elimination of crystalloid or colloid solutions during inhalational anesthesia have not been adequately investigated. Hemoglobin dilution and fluid kinetic model have been shown to reveal the distribution and elimination of various kinds of fluids. Therefore, we assessed fluid space changes after Hartmann's solution or hydroxyethyl starch solution (HES) infusion during desflurane anesthesia. METHODS: We infused 20 ml/kg of Hartmann's solution, 8.5 ml/kg of Hextend(R) and 8.5 ml/kg of Voluven(R) during 20 min, after anesthesia induction and before surgical incision, and measured the hemoglobin changes. We used mass balance equations and a fluid kinetic model to evaluate the changes of fluid space. In the fluid kinetic model, we used one volume model, which allows estimation of the size of the body fluid space expanded by the fluid (V) and the elimination rate constant (kr). RESULTS: The expanded plasma volume of three different fluids, calculated using mass balance equations, showed a similar degree of expansion during infusion, however, after finishing infusion, the dilution effect of Hartmann's solution decreased rapidly and lasted less than HES. Fluid kinetic model shows the mean size of V of 12.3 +/-5.9 L for Hartmann' solution, 5.2 +/- 1.6 L for Hextend, and 4.5 +/- 1.6 L for Voluven. Corresponding kr values were 263.0 +/- 161.8, 36.5 +/- 31.8, and 34.1 +/- 21.3 ml/min, respectively. CONCLUSIONS: The distribution volume of intravenous fluids analyzed by kinetic model showed that crystalloid fluid has a similar volume distribution compared to extracellular fluid and HES distributed to a volume larger than blood volume. Analysis and simulation of plasma volume expansion using this model provide a helpful tool for anesthesiologists planning fluid therapy.

Intermittent Interscalene Brachial Plexus Block vs. Continuous Intraarticular Infusion for the Management of Postoperative Pain after Shoulder Surgery

BACKGROUND: Severe postoperative pain is a well-known problem following shoulder surgery. This study evaluates the clinical efficacy of intermittent interscalene brachial plexus block (ISBPB) compared with that of continuous intraarticular infusion (IAPCA) for the management of postoperative pain after shoulder surgery. METHODS: Fifty seven patients, scheduled for shoulder surgery during general anesthesia, were randomly allocated to one of two groups. Group ISBPB (n = 19) received a preoperative interscalene brachial plexus block using 20 ml of 0.5% bupivacaine followed by insertion of a 20-gauge polyamide catheter. This catheter was connected to a patient-controlled analgesia pump set immediately after surgery to administer a bolus of 0.75% ropivacaine 15 ml at lockout time intervals 8 hours. Group IAPCA (n = 38) received patient- controlled analgesia with 0.2% ropivacaine 100 ml (basal rate 2 ml/hr, bolus 0.5 ml, lockout time 15 min). Both groups received intravascular patient-controlled analgesia with fentanyl 10? 15 microg/ml (basal rate 1 ml/hr, bolus 2 ml, lockout time 15 min). All patients were given pethidine 25 or 50 mg when visual analogue score (VAS) >40 mm. VAS, circulatory and respiratory stress parameter (heart rate, noninvasive blood pressure and respiratory rate) and consumption of pethidine were measured during 72 hours following surgery at intervals of 8 hours. RESULTS: The mean VAS scores in the ISBPB group were significantly lower than in the IAPCA group for 72 hr after surgery (P < 0.01). Pethidine consumption in the ISBPB group was significantly lower than in the IAPCA group (P < 0.01). CONCLUSIONS: We concluded that intermittent interscalene brachial plexus block is an effective method of postoperative analgesia after major shoulder surgery.

Comparison of Fluid Kinetic Model of Normal Saline with Hartmann's Solution in Adult Volunteers

BACKGROUND: Changes in the volume of fluid space expanded by intravenous infusion of crystalloid solution have been analyzed using mathematical models. Crystalloids with similar osmolality would reveal no significant differences in distribution and elimination from the body. But each solution has different ionic composition, this can affect fluid volume kinetics. Therefore, we evaluated the fluid volume kinetics of normal saline and Hartmann's solution. METHODS: After infusion of 15 ml/kg of normal saline (n=5) and Hartmann's solution (n = 4) over 30 min and measured a serial hemoglobin concentration. The changes were expressed as fractional dilution and then plotted against time. The curves were fitted to two-volume model using non linear least square fitting process. RESULTS: Central and peripheral volume space were present. There were no significant differences between the two groups on central volume, peripheral volume and expansion ratio of fluid space per body weight and expansion ratio of peripheral volume. The expansion ratio of central volume was greater in Hartmann's solution than normal saline from 25 min to 60 min after infusion. Hartmann's solution expanded fluid space higher than normal saline on initial period. CONCLUSIONS: There were no significant differences in fluid kinetic parameters between normal saline and Hartmann's solution. However, the volume expansion effect of Hartmann's solution was more rapid than normal saline in early infusion period.

Endotracheal Tube Obstruction by Tooth of Facial Trauma Patient: A case report / 대한마취과학회지

Difficulties in ventilation are sometimes encountered in intubated patients. In these cases, endotracheal tube kinking, or an obstruction by secretion or foreign bodies should be considered. We experienced an endotracheal tube obstruction by a foreign body. The patient was a 36 year old woman who had a traffic accident. She had already been intubated when entering operating room. However, ventilation was difficult, which was presumed to be caused by an endotracheal tube obstruction. The endotracheal tube was examined by fiberoptic bronchoscopy and the patient's broken tooth was found inside the endotracheal tube. The endotracheal tube was exchanged and ventilation was normalized.

Modelling the Expandable Body Fluid Space after I.V. Fluid Infusion / 대한마취과학회지

BACKGROUND: Changes in the volume of the fluid space expanded by i.v. infusion of crystalloid solution have been analysed recently using mathematical models. The models are based on the assumption that the body strives to maintain volume homeostasis of fluid spaces and that the rate of restoration is a function of deviation from resting volume. METHODS: In this work mathematical models were developed to represent the kinetics of volume changes of fluid spaces associated with infusion of Ringer's solution. Based on the characteristics of fluid transportation, two expansion models were tested. The single-fluid space model has a single volume into which fluid is fed and from which fluid is left, and the two-fluid space model has another space in addition to the first volume so that fluid exchanges between these two spaces are possible. Volunteers (six men) were given Hartman's solution for 30 min and the changes in blood hemoglobin were detected. RESULTS: From the comparison with experimental data, the single-fluid space model was found to represent adequately in all volunteers, however, two-fluid space model was found to represent 75% of volunteers. CONCLUSIONS: These models may be useful in the description and analysis of the effects of i.v. fluid therapy.

Anesthetic Implication of Hemoglobin-M: A case report / 대한마취과학회지

Cyanosis in children is most often caused by pulmonary disease, or cyanotic heart disease but is rarely caused by hematological problems such as methemoglobinemia and sulfhemoglobinemia. Abnormal hemoglobins with a reduced oxygen affinity are an exceptionally uncommon cause of cyanosis in children. Hemoglobin-M (Hb-M) is rapidly auto-oxidized into the met-form resulting in the loss of its O2-binding ability. This hemoglobinopathy is inherited in an autosomal dominant pattern and is characterized by marked cyanosis. Hb-M affects the anesthetic management because of the anomalous absorption spectrum of Hb-M in standard pulse oximetry. Sufficient O2 delivery should be maintained by keeping a high FiO2 and intermittently checking the O2 delivery state using arterial blood gas analysis. We reported our experience of the anesthetic management of a patient with hemoglobin M.

Effects of Fresh Gas Flow Rate on the Ratio of Expired to Inspired Anesthetic Concentration / 대한마취과학회지

BACKGROUND: One way to make rapid increase in alveolar anesthetic concentration includes using high fresh gas flow rates. Fresh gas flow rates should be increased to compensate the amount of uptake either. This study was performed to elucidate optimal fresh gas flow rates for rapid induction by comparison of changes of ratio of expired to inspired concentration. METHODS: The study population was composed of 107 patients undergoing thyroidectomy. Patients were randomly allocated to one of three groups who received desflurane or sevoflurane or isoflurane. Each group was randomly subdivided into three groups who received one of the fresh gas flow rate: 2, 5 or 10 L/min. Inspired anesthetic concentration (Fi) and expiratory anesthetic concentration (Fe), delivered concentration (FD) were recorded. RESULTS: With same fresh gas flow rates, there were significant differences between Fe/Fi of desflurane, sevoflurane, isoflurane. With same anesthetics, Fe/Fi of desflurane and sevoflurane were not influenced by fresh gas flow rates. But Fe/Fi of isoflurane at 2 L/min was significantly lower than 5 L/min and 10 L/min. Fi/FD of desflurane at 10 L/min did not differ from sevoflurane. At 2 L/min and 5 L/min, Fi/FD of desflurane was highest and then sevofluane, isoflurane in that order. CONCLUSIONS: Because rates of Fe/Fi of desflurane and sevoflurane were not influenced by fresh gas flow rates, 2 L/min of fresh gas flow rates could be selected. However, considering the wash-in time in circuit, optimal choice of fresh gas flow rate for desflurane and sevoflurane could be 5 L/min, that of isoflurane be 10 L/min.

Postoperative Pain Control with Epidural Meperidine Infusion / 대한통증학회지

BACKGROUND: Epidural opioids are commonly used for postoperative analgesia. However, the side effects of epidural opioids include respiratory depression, sedation, pruritus, nausea, vomiting and urinary retention. Meperidine, due to its intermediate lipid solubility and local anesthetic properties, permits postoperative analgesia. The aim of this study was to compare meperidine alone to meperidine coupled with bupivacaine, and to determine the effects of epidural meperidine without bupivacaine, when used for epidural analgesia following hepatectomy abdominal surgery. METHODS: Patients received thoracic epidural analgesia with meperidine alone (3.5 mg/ml in saline) or with additional bupivacaine (0.15%) for 2 days after surgery. Postoperative pain was assessed using a visual analog scale (VAS) pain score 2 days after the operation, with the incidence and dose supplementation also evaluated. Postoperative side effects were assessed using a 3 grade system. RESULTS: No significant difference was found between the two groups in terms of age and weight, or in the pain scores, side effects, incidence and dose supplementation. CONCLUSIONS: 3.5 mg/ml epidural meperidine at a dose of 2 ml/hr provides effective postoperative analgesia.

Anesthetic Experience in Ex Situ Resection of The Liver: A case report / 대한마취과학회지

Ex situ resection of the liver is an alternative surgical procedure for patients with conventionally unresectable hepatic tumors, and with contraindications to liver transplantation. We experienced a case of ex situ resection of the liver in a 40-year-old female patient suffering from sclerosing hepatocellular carcinoma. Preoperative liver function was normal. The duration of the anhepatic period was 2 hours and 55 minutes. No severe hemodynamic or pulmonary complications, and no significant metabolic or coagulatory disorders occurred. To obtain good results by ex situ resection of the liver, anesthesiologist should understand the physiology of the anhepatic period and guard against possible problems during the operation. (Korean J Anesthesiol 2004; 46: 127~130)

Changes of Hepatic Microcirculation Measured by Thermal Diffusion Probe after Vasopressor Infusion

PURPOSE: Various vasopressor agents are used to raise systemic vascular resistance (SVR) during liver transplantation. After grafted liver was reperfused, postreperfusion syndrome could be treated with various vasopressors. However, epinephrine can decrease the splanchnic perfusion and oxygen saturation and then hepatic blood flow would be jeopardized. Decreased hepatic blood flow might result in centrilobular necrosis which contributes to disruption of liver functions. We tried to know the effect of epinephrine on tissue perfusion of the liver. METHODS: In this study, measurement of hepatic microcirculation (HMC) and hemodynamic changes was performed in eight dogs to investigate the effect of vasopressors on hepatic microcirculation. Animals were divided into four groups in which low-dose epinephrine (0.05mug/Kg/min) and high-dose epinephrine (0.5mug/Kg/min) were randomly infused into the systemic vein and portal vein (1/6 of systemic dose) for ten minutes. Hepatic microcirculation was measured by Thermal Diffusion Probe. RESULTS: At low-dose systemic infusion of epinephrine, mean arterial bloodpressure (MABP), cardiac output (CO), and hepatic microcirculation (HMC) were significantly increased but systemic vascular resistance (SVR) was decreased. On high-dose epinephrine, MABP, CO (P=0.01), and SVR were significantly increased without changes of HMC. Intraportal infusion of low- and high-dose epinephrine increased hepatic vein pressure and SVR, respectively. CONCLUSION: These results would provide clues that systemic low-dose epinephrine infusion is enough to raise HMC and high-dose infusion of epinephrine to raise SVR could be used without jeopardizing HMC.

Fatal Pulmonary Hemorrhage after Reperfusion of a Grafted Liver: A case report / 대한마취과학회지

We report a case of fatal pulmonary hemorrhage developed after reperfusion of grafted liver during a living-related liver transplantation. A 53 year-old man who had hepatic encephalopathy grade 4 with fulminant hepatic failure was scheduled for a living-related liver transplantation. Preoperative evaluation showed fever, hypoxia, hypotension, pneumonia, and pulmonary edema. Cardiopulmonary stability was maintained with oxygen therapy and inotropic agents. During the anhepatic period, the patient's vital signs remained stable with inotropic agents except one episode of sudden hypotension presumably due to right heart strain. However, hypoxia, acidosis, and electrolyte imbalance were becoming worsen in spite of variable treatments for correction. Immediately after reperfusion, a sudden increase of central venous pressure and pulmonary artery pressure was noticed. evere bradyarrhythmia, hypotension, hemoptysis, hypoxia, and acidosis were followed by cardiac arrest. Cardiopulmonary resuscitation was not successful and the patient expired

Causes of a Sudden Hypotension on Preanhepatic Stage during Liver Transplantation / 대한마취과학회지

BACKGROUND: Various hemodynamic disturbances and a rapidly changing circulatory blood volume necessitate the proper management of fluid administration. The causes of sudden hypotension can be anticipated with the usual monitoring devices. However, more accurate diagnosis of such event can only be made by actual measurement of cardiac output. And such an event may be related to cardiac depression due to autonomic disturbances. To elucidate the cause of sudden unexplainable hypotension during the preanhepatic stage, we analysed the hemodynamic data of patients undergoing liver transplantation prospectively. METHODS: Patients were divided into a normal and a hypotensive group, according to the presence of an episode of hypotension. The hypotensive group was further divided into an explainable and an unexplainable group, if causes were known or not. Preoperative echocardiograms and Child-Pugh scors were also analysed. The normal and unexplainable hypotensive groups were compared using Mann-Whitney non-parametric, Chi-square and Wilcoxon-signed rank tests. P<0.05 was considered statistically significant. RESULTS: The incidence of hypotension was 25.2%. A severe unexplainable hypotensive episode occurred 9.3% of the the liver transplantations. Causes of hypotension were preload deficiency, vena caval compression, bleeding, and vagal reflex. Unexplainable hypotensive patients showed decreased ejection fraction (cardiac depression) and systemic vasodilatation. CONCLUSIONS: These results suggest hepato-dyscirculatory syndrome is the main cause of unexplainable hypotension during the preanhepatic stage.

Anesthesia for Synchronous Liver-Kidney Transplantation / 대한마취과학회지

Until recently liver transplantation has been considered a contraindication in patients with multi-organ failure. However, developements in surgery and anesthetic technique involving intraoperative extrarenal purification provide adequate conditions for performing synchronous liver-kidney transplantation (SLKT), and it is clear that double transplantation is the best therapeutic option in end stage liver and kidney disease. Liver transplantation involves a large blood loss and fluid replacement, as well as administration of large amounts of blood products. Patients with end stage liver and kidney disease have a reduced capacity to excrete free water, predisposing them to an accumulation of extravascular water. Precise monitoring and the intraoperative use of an extrarenal purification technique to maintain these patients within acceptable hydroelctrolyte and hemodynamic parameters is needed. We experienced two cases of SLKT and report on anesthetic management and problems.

Anesthesia for Liver Transplantation in Patients with Fulminant Hepatic Failure under Intracranial Pressure and Jugular Venous Oxygen Saturation Monitoring / 대한마취과학회지

BACKGROUND: Fulminant hepatic failure is characterized by rapid progressive liver failure with the onset of encephalopathy within a few weeks of the appearance of jaundice. This illness is frequently complicated by hemodynamic instability, multiple organ dysfunction and intracranial hypertension associated with cerebral edema, which is the most common cause of death in this condition. We reviewed 8 cases of liver transplantation with fulminant hepatic failure with respect to anesthetic management and neurologic monitoring. METHODS: We analyzed anesthetic management, intracranial pressure (ICP), cerebral perfusion pressure (CPP), jugular venous oxygen saturation (SjvO2) and hemodynamics retrospectively during liver transplantation in 8 patients with fulminant hepatic failure. Intracranial hypertension was defined as an ICP >or= 20 mmHg for at least 5 minutes. The goal of management is to keep the CPP above 40 - 50 mmHg and ICP below 30 - 40 mmHg. There were 3 cases of hepatorenal syndrome and continous veno-venous hemodiafiltration (CVVHD) was used in 2 cases. RESULTS: All patients showed characteristic hyperdynamic circulation with severe vasodilation and vasopressive drugs were needed to maintain CPP. The episodes of intracranial hypertension occurred in all patients during transplantation. To decrease ICP, medical therapy with mannitol, furosemide and thiopental infusion were required. Intracranial hemorrhagic complications occurred in 3 cases. SjvO2 decreased transiently below 60% in 3 cases. However, it was improved with an increase of PaCO2 by hypoventilation and maintained above 60 - 80% in all cases. CONCLUSIONS: This data suggests that there is a risk of brain injury secondary to elevated ICP and low CPP during liver transplantation. ICP, CPP and SjvO2 monitoring in patients with fulminant hepatic failure can be useful for the prompt recognition of intracranial hypertension and for guiding therapy. However, correction of the coagulopathy before placement of the ICP tranducer must be performed to prevent hemorragic complications.