Transoesophageal doppler compared to central venous pressure for perioperative hemodynamic monitoring and fluid guidance in liver resection

Major hepatic resections may result in hemodynamic changes. Aim is to study transesophageal Doppler [TED] monitoring and fluid management in comparison to central venous pressure [CVP] monitoring. A follow-up comparative hospital based study. 59 consecutive cirrhotic patients [CHILD A] undergoing major hepatotomy. CVP monitoring only [CVP group], [n=30] and TED [Doppler group], [n=29] with CVP transduced but not available on the monitor. Exclusion criteria include contra-indication for Doppler probe insertion or bleeding tendency. An attempt to reduce CVP during the resection in both groups with colloid restriction, but crystalloids infusion of 6 ml/kg/h was allowed to replace insensible loss. Post-resection colloids infusion were CVP guided in CVP group [5-10 mmHg] and corrected flow time [FTc] aortic guided in Doppler group [>0.4 s] blood products given according to the laboratory data. Using the FTc to guide Hydroxyethyl starch 130/0.4 significantly decreased intake in TED versus CVP [1.03 [0.49] versus 1.74 [0.41] Liter; P<0.05]. Nausea, vomiting, and chest infection were less in TED with a shorter hospital stay [P<0.05]. No correlation between FTc and CVP [r=0.24, P > 0.05]. Cardiac index and stroke volume of TED increased post-resection compared to baseline, 3.0 [0.9] versus 3.6 [0.9] L/min/m [2], P<0.05; 67.1 [14.5] versus 76 [13.2] ml, P<0.05, respectively, associated with a decrease in systemic vascular resistance [SVR] 1142.7 [511] versus 835.4 [190.9] dynes.s/cm[5], P<0.05. No significant difference in arterial pressure and CVP between groups at any stage. CVP during resection in TED 6.4 [3.06] mmHg versus 6.1 [1.4] in CVP group, P=0.6. TED placement consumed less time than CVP [7.3 [1.5] min versus 13.2 [2.9], P<0.05]. TED in comparison to the CVP monitoring was able to reduced colloids administration post-resection, lower morbidity and shorten hospital stay. TED consumed less time to insert and was also able to present significant hemodynamic changes. Advanced surgical techniques of resection play a key role in reducing blood loss despite CVP more than 5 cm H[2]O. TED fluid management protocols during resection need to be developed

Entropy-guided end-tidal desflurane concentration during living donor liver transplantation

The three phases of living donor liver transplantation [LDLT] represent different liver conditions. The aim is to study the required end-tidal desflurane concentration [ET-Des] guided with entropy monitoring for the depth of anesthesia. After the Ethics and Research Committee approval, 40 patients were included in this prospective study. Anesthesia was maintained with Desflurane-O2-air. State entropy [SE] and Response entropy [RE] were kept between 40 and 60. Age and Model for End-stage Liver Disease [MELD] score were 45 +/- 10 years and 15.43 +/- 3.92, respectively. ET-Des were significantly lower in the anhepatic phase [2.8 +/- 0.4%] than in the pre-anhepatic and neohepatic phases [3.3 +/- 0.3%, 3.47 +/- 0.3%, respectively, P<0.001]. The SE and RE for pre-anhepatic, anhepatic, and neohepatic phases were [45.6 +/- 3.7, 47.4 +/- 3.2], [44.7 +/- 2.1, 46.4 +/- 2.04], and [46.1 +/- 3.3, 47.9 +/- 3.3], respectively, with no significant changes between the phases, P > 0.05. Total operative time was 651 +/- 88 minutes, and for each phase it was 276 +/- 11, 195 +/- 55, and 191 +/- 24 minutes, respectively. Significant changes were found in hemoglobin g/dl and hematocrit% between the three phases [10.28 +/- 1.5, 30.48 +/- 4.3], [9.45 +/- 1.34, 28.36 +/- 4.1], and [8.88 +/- 1.1, 26.63 +/- 3.5], P<0.05. The heart rate and mean blood pressures were stable despite the cardiac index demonstrated a significant reduction during the anhepatic phase [2.99 +/- 0.22] when compared to the pre-anhepatic and neohepatic phases [3.60 +/- 0.29] and [4.72 +/- 0.32], respectively, [P<0.05]. There was a significant correlation between CI and ET-Des% [r=0.604, P<0.05]. Inhalational anesthetic requirements differed from one phase to another during LDLT, with requirements being the least during the anhepatic phase. Monitoring of the anesthesia depth was required, to avoid excess administration, which could compromise the hemodynamics before the critical time of reperfusion