Use of transesophageal doppler as a sole cardiac output monitor for reperfusion hemodynamic changes during living donor liver transplantation: an observational study

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]. A prospective observational study. 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 guided by corrected flow time [FTc] of the TED. Packed red blood cells [RBCs] were only given when hematocrit was less than 25%. Rotational thromboelastometry [ROTEM] and standard laboratory tests were used to guide component blood products requirements. Post-reperfusion, the COP, Cardiac Index [CI] and stroke volume [SV] increased significantly at all points of measurements; this was associated with a significant decrease in systemic vascular resistance [SVR] [P?<.05]. Immediately post-reperfusion, for 5 minutes, mean arterial blood pressure [ABP] dropped significantly [P<.05], and 14 out of the 25 patients required boluses of epinephrine [10 micro g] to restore the mean ABP; 3 of the 14 patients required norepinephrine infusion till the end of surgery. Central venous pressure [CVP] and urine output [UOP] at all measures were maintained adequately with FTc-guided fluid replacement. Eight out of the 25 patients required no blood transfusion, and 4 of the 8 patients required no catecholamine support. TED as a sole monitor for COP was able to present significant and reliable changes in the cardiovascular status of the recipients during reperfusion, which could help to guide fluid-and drug-supportive therapy in this population of patients. This preliminary study needs to be applied on a larger scale

Changes of serum magnesium and phosphate concentrations during and after hepatic resections for cirrhotic patients

A prospective study to evaluate alternations in serum concentrations of total magnesium[TMg], ionized magnesium [iMg], inorganic phosphorus [PO4], lactic acid [LA], aspartate aminotransferase [AST], alanine aminotransferase [ALT] during and after liver resections in liver cirrhotic patients and their inter-relationships. Twenty-five patients were included with Child-Pughs B classification Samples were taken before anesthesia induction, during liver resection, thiryt minutes after rBsection and reperfusion and daily for 3 days TMg was adjusted for albumin concentration Mg and PO4 supplementations were not given intraoperatively except for the magnesium found in the normal composition of Plasmatyte A, a multiple electrolyte fluid composition of pH 7.4 [6.5-8]used for volume replacement Results showed a significant decline in TMg, iMg and PO4 during liver resection [p=0.005 p= 0.008 p=0.068 respectively] and after resection [p=0.005 p=0.005 p=0.021 respectively]. The decline of TMg exceeded the decline of iMg to below the normal laboratory reference ranges intraoperattvely and postoperatively on day 1 in 15 patients. TMg correlated positively with iMg [r=0.55 p=0.01]. Significant perioperattve increase in LA, AST and ALT [p<0.05] were observed with a gradual decreased on day2 and 3. LA correlated positively with both AST and ALT [r=0.54, p<0.01 and r=0.53, p<0.01, respectively] but negatively with both TMg and iMg [r=-031 p=0.01, r=;'-0.22, p=0.09]. Hypoalbuminaemia was frequently reported among this population, in conclusion total magnesium overestimated the incidence of hypomagnesaemia when significant hypoalbuminemia is present, ionised magnesium should be used instead, intra-operative and post-operative hypophosphataemia occurs frequently. Monitoring and intravenous replacement is hence recommended. Lactate could be used as an indirect indicator for liver function. Possible preventive measures need to be investigated in future studies

Perioperative serum beta-2-micro globulin concentration in obstructive jaundice

Obstructive jaundice [OJ] can lead to hepatic and renal impairment. The aim of this study was to measure levels of serum Beta 2 Micro globulin [SB2M] in patients with OJ undergoing explorative surgery for relief of the obstruction and to determine the usefulness of such a measurement as a monitor for renal impairment relative to other measures of renal function. SB2M levels [mg/L] were not above the normal reference range preoperatively [2.39 [1.7-4.8]], intraoperatively [2.2[0.27-3.4], p = 0.08], six hours postoperatively [1.9 [1.03-4.8], p = 0.2] and after 24 hours [1.92 [0.95-4.9], p = 0.4] when compared to preoperative values. None of the patients involved in the study developed acute renal failure or suffered from severe renal or hepatic impairment preoperatively. Urea, creatinine and creatinine clearance [CrCl] perioperative changes were insignificant. Correlation between SB2M and CrCl was significant preoperatively [r = -0.41, p =0.02] but marginally failed to reach statistical significance postoperatively [r = -0.35, p = 0.053]. No significant correlation existed between SB2M and the following creatinine, urea, bilirubin and prothrombin time [PT]. Postoperative 24 hours PT was 12.87 [12-19.67] seconds, this was significantly lower than the preoperative PT 13.46 [12-26] seconds [p = 0.001]. No blood products were used during surgery. OJ was not associated with an increase in serum B2M blood levels. Severe renal failure was not encountered due to stability of the haemodynamic parameters and the guided fluid therapy. Few patients showed some degree of renal dysfunction but this did not develop to failure. This study cannot recommend the routine measurement of SB2M, as it did not add to the existing routine renal function tests. Improvement in PT after relief of OJ indicates the need for an early surgical intervention