Successful ABO-Incompatible Living Donor Liver Transplantation in a Patient with an Anaphylactic Reaction to Fresh Frozen Plasma During Therapeutic Plasma Exchange: A Case Report.

BACKGROUND: ABO-incompatible living donor liver transplantation (ABOi LDLT) is a complex procedure involving the reduction of anti-A and anti-B antibodies by therapeutic plasma exchange (TPE) to prevent acute antibody-mediated rejection. Fresh frozen plasma (FFP) is often used as replacement fluid during TPE. CASE DESCRIPTION: We report an ABOi LDLT case in which the patient experienced an anaphylactic reaction to FFP during TPE. Additional TPE was performed using 5% albumin as replacement fluid. ABOi LDLT was successfully performed by adapting the transfusion strategy to avoid FFP and cryoprecipitate and to administer washed platelets. CONCLUSION: This case highlights the importance of careful preoperative assessment, multidisciplinary coordination, and individualized approaches in ABOi LDLT, especially when the patient has an anaphylactic reaction to FFP.

Preoperative Intrathecal Morphine is Associated With Reduced Postoperative Pain, Agitation, and Delirium In Living Donor Kidney Transplantation Recipients.

BACKGROUND: Postoperative delirium after organ transplantation can lead to increased length of hospital stay and mortality. Because pain is an important risk factor for delirium, perioperative analgesia with intrathecal morphine (ITM) may mitigate postoperative delirium development. We evaluated if ITM reduces postoperative delirium incidence in living donor kidney transplant (LDKT) recipients. METHODS: Two hundred ninety-six patients who received LDKT between 2014 and 2018 at our hospital were retrospectively analyzed. Recipients who received preoperative ITM (ITM group) were compared with those who did not (control group). The primary outcome was postoperative delirium based on the Confusion Assessment Method for Intensive Care Unit results during the first 4 postoperative days. RESULTS: Delirium occurred in 2.6% (4/154) and 7.0% (10/142) of the ITM and control groups, respectively. Multivariable analysis showed age (odds ratio [OR]: 1.07, 95% CI: 1.01-1.14; P = .031), recent smoking (OR: 7.87, 95% CI: 1.43-43.31; P = .018), preoperative psychotropics (OR: 23.01, 95% CI: 3.22-164.66; P = .002) were risk factors, whereas ITM was a protective factor (OR: 0.23, 95% CI: 0.06-0.89; P = .033). CONCLUSIONS: Preoperative ITM showed an independent association with reduced post-LDKT delirium. Further studies and the development of regional analgesia for delirium prevention may enhance the postoperative recovery of transplant recipients.

Living Donor Liver Transplantation for an Infant Having Tracheostomy and Subglottic Stenosis: A Case Report.

BACKGROUND: It is uncommon to perform liver transplantation for patients with end-stage liver disease having tracheostomy. Usually, the tracheostomy cannula is changed to an oral endotracheal tube (ETT) before operation because ETT is easy to handle during operation. If routine oral ETT insertion is difficult, we should seek other solutions. CASE DESCRIPTION: We report a successful conversion from tracheostomy tube to ETT in a patient with subglottic stenosis. The patient was an 8-month-old infant who was scheduled for living donor liver transplantation due to acute hepatic failure. The original plan was to convert the tracheostomy tube to oral ETT, which failed due to aggravation of subglottic stenosis. An otolaryngologist performed balloon dilatation surgery, and ETT was successfully intubated. Owing to a multidisciplinary approach, the surgery was successfully performed without fatal adverse events, and the patient was later discharged with a tracheostomy. CONCLUSIONS: It is unusual for pediatric patients with tracheostomy tubes to undergo major surgeries like liver transplantation. We hope that this case of successful anesthetic management based on a multidisciplinary approach suggests new ideas to anesthesiologists seeking safe anesthesia.

Factors to consider during anesthesia in patients undergoing preemptive kidney transplantation: a propensity-score matched analysis.

BACKGROUND: International guidelines have recommended preemptive kidney transplantation (KT) as the preferred approach, advocating for transplantation before the initiation of dialysis. This approach is advantageous for graft and patient survival by avoiding dialysis-related complications. However, recipients of preemptive KT may undergo anesthesia without the opportunity to optimize volume status or correct metabolic disturbances associated with end-stage renal disease. In these regard, we aimed to investigate the anesthetic events that occur more frequently during preemptive KT compared to nonpreemptive KT. METHODS: This is a single-center retrospective study. Of the 672 patients who underwent Living donor KT (LDKT), 388 of 519 who underwent nonpreemptive KT were matched with 153 of 153 who underwent preemptive KT using propensity score based on preoperative covariates. The primary outcome was intraoperative hypotension defined as area under the threshold (AUT), with a threshold set at a mean arterial blood pressure below 70 mmHg. The secondary outcomes were intraoperative metabolic acidosis estimated by base excess and serum bicarbonate, electrolyte imbalance, the use of inotropes or vasopressors, intraoperative transfusion, immediate graft function evaluated by the nadir creatinine, and re-operation due to bleeding. RESULTS: After propensity score matching, we analyzed 388 and 153 patients in non-preemptive and preemptive groups. The multivariable analysis revealed the AUT of the preemptive group to be significantly greater than that of the nonpreemptive group (mean ± standard deviation, 29.7 ± 61.5 and 14.5 ± 37.7, respectively, P = 0.007). Metabolic acidosis was more severe in the preemptive group compared to the nonpreemptive group. The differences in the nadir creatinine value and times to nadir creatinine were statistically significant, but clinically insignificant. CONCLUSION: Intraoperative hypotension and metabolic acidosis occurred more frequently in the preemptive group during LDKT. These findings highlight the need for anesthesiologists to be prepared and vigilant in managing these events during surgery.

Sudden mode change of permanent pacemaker during living donor liver transplantation - A case report.

BACKGROUND: Pacemakers assist circulation by generating electrical impulses. Patients with pacemakers scheduled to undergo surgery are vulnerable to device-related complications. Therefore, careful perioperative management is required to prevent undesirable events. CASE: A 66-year-old man with alcohol-related hepatocellular carcinoma was referred for liver transplantation. The pacemaker was inserted preoperatively to manage sick sinus syndrome and paroxysmal atrial fibrillation. Overall liver transplantation was performed without any adverse events. However, the pacemaker suddenly failed to provide regular pacing rhythm during abdominal closure. Fortunately, the native heart rate was maintained above 70 beats per minute and blood pressure did not fluctuate after pacing failure. After retrospective analysis, the duration setting of preoperative pacemaker reprogramming (24 h) was revealed as the cause of unexpected pacing failure. CONCLUSIONS: Anesthesiologists should be alert in patients with pacemakers because minor errors may lead to inadvertent failure of pacing or severe hemodynamic instability.

Cumulative postoperative change in serum albumin levels and organ failure after living-donor liver transplantation: A retrospective cohort analysis.

Many studies have reported that hypoalbuminemia could be associated with organ failure after liver transplantation. However, most of them focused on serum albumin levels measured at specific time points and not on the trend of serum albumin change. We investigated whether a cumulative postoperative change in serum albumin level up to postoperative day (POD) 5 is related to organ failure in patients who underwent living-donor liver transplantation (LDLT). Data of adult recipients who underwent LDLT between January 2016 and December 2020 at a single tertiary hospital were reviewed (n = 399). After screening, three patients were excluded because of insufficient data. A cumulative change in serum albumin level was demonstrated using the area under the threshold (AUT, threshold = 3.0 g/dL) of the serum albumin curve up to POD 5. Based on the AUT, the patients were divided into a high-decrease group (n = 156) and a low-decrease group (n = 240). All analyses were conducted using 1:1 propensity score matching. The primary endpoint was the Sequential Organ Failure Assessment (SOFA) score on POD 5. The secondary endpoints were postoperative hospital stay and postoperative 90-day mortality. A total of 162 patients were included. The SOFA score on POD 5 was significantly higher in the High-decrease group compared with the Low-decrease group (5.2 ± 2.6 vs. 4.1 ± 2.3; mean difference: 1.1, 95% CI: 0.3 to 1.8; P = 0.005). However, the length of postoperative hospital stay (P = 0.661) and 90-day mortality (P = 0.497) did not differ between the groups. In conclusion, a cumulative postoperative change in serum albumin level up to POD 5 could help predict postoperative organ failure on POD 5 in patients who underwent LDLT.

Blood Salvage and Autotransfusion With Single Leukoreduction Does Not Increase the Risk of Tumor Recurrence After Liver Transplantation for Advanced Hepatocellular Carcinoma.

OBJECTIVE: The aim of this study was to determine whether autotransfusion of salvaged blood with single leukoreduction is associated with post-transplant tumor recurrence in patients with advanced hepatocellular carcinoma (HCC). BACKGROUND: Previous studies have consistently demonstrated the safety of autotransfusion of salvaged and leukoreduced blood during liver transplantation for HCC. However, the effects of this technique remained unknown for advanced HCC. METHODS: Of 349 patients who underwent living donor liver transplantation for advanced HCC: 74 of 129 without autotransfusion were matched with 74 of 220 with autotransfusion using propensity score based on tumor biology, allogeneic transfusion, and others. Survival analysis was performed with death as a competing risk event. The primary outcome was HCC recurrence. RESULTS: Recipients in autotransfusion group received 811 (497-1247) mL of salvaged blood with single leukoreduction. In the matched cohort, cumulative overall recurrence probability at 1/2/5 years after transplantation was 24.6%/ 38.3%/39.7% for nonautotransfusion group and 16.2%/23.1%/32.5% for autotransfusion group. There were no significant differences between the 2 groups in overall recurrence [hazard ratio (HR) = 0.72 (0.43-1.21)], intrahepatic recurrence [HR = 0.70 (0.35-1.40)], and extrahepatic recurrence [HR = 0.82 (0.46-1.47)]. Also, there were no significant differences in overall death [HR = 0.57 (0.29-1.12)], HCC-related death [HR = 0.59 (0.29-1.20)], and HCC-unrelated death [HR = 0.48 (0.09-2.65)]. CONCLUSIONS: When allogeneic transfusion was matched, autotransfusion was not significantly related to HCC recurrence, with more favorable probabilities for autotransfusion, in patients with advanced HCC. Thus, blood salvage and autotransfusion could be safely used with single leukoreduction, without double-filtered leukoreduction, during liver transplantation for HCC with potential benefits from avoiding allogeneic red blood cell transfusion.

Realization of improved outcomes following liver resection in hepatocellular carcinoma patients aged 75 years and older.

PURPOSE: Little is known about liver resection (LR) in hepatocellular carcinoma (HCC) patients older than 75 years of age. This study aimed to compare the postoperative and long-term outcomes of hepatectomy in this patient population according to operation period. METHODS: This study included 130 elderly patients who underwent LR for solitary treatment-naïve HCC between November 1998 and March 2020. Group 1 included patients who underwent LR before 2016 (n = 68) and group 2 included those who underwent LR during or after 2016 (n = 62). RESULTS: The proportion of major LR, anatomical LR, and laparoscopic LR (LLR) in group 1 was significantly lower than those in group 2. Also, the median operation time, amount of blood loss, hospitalization length, rates of intraoperative blood transfusion, and complications in group 2 were less than those in group 1. In the subgroup analysis of group 1, high proteins induced by vitamin K absence or antagonist-II, long hospitalization, and LLR were closely associated with mortality. In the subgroup analysis of group 2, however, none of the factors increased mortality. Nevertheless, the presence of tumor grade 3 or 4 and the incidence of microvascular invasion were higher in group 1 than in group 2, and the disease-free survival and overall survival were better in group 2 than in group 1 because of minimized blood loss and quicker recovery period by increased surgical techniques and anatomical approach, and LLR. CONCLUSION: LR in elderly HCC patients has been frequently performed recently, and the outcomes have improved significantly compared to the past.

Liver transplantation of a patient with extreme thrombocytopenia - A case report.

BACKGROUND: Patients with chronic liver disease (CLD) planned for liver transplantation (LT) often show severe thrombocytopenia, but there is a lack of evidence in deciding the threshold for prophylactic platelet transfusion. CASE: A 47-year-old female with acute liver failure was referred for LT. Despite daily transfusion of platelets, platelet counts remained under 10,000/µl. During LT, 2 units of single donor platelets (SDP) were transfused. Although platelet counts remained extremely low (3,000-4,000/µl) no diffuse oozing was observed and the blood loss was 860 ml. Postoperatively, there was no sign of active bleeding or oozing, and the patient received only 1 unit SDP transfusion. CONCLUSIONS: CLD patients may have severe thrombocytopenia. However, primary hemostasis may not be significantly hindered due to the existence of rebalanced hemostasis. Prophylactic platelet transfusion in these patients should not be decided based on platelet counts only, but also take other coagulation tests and clinical signs into consideration.

Decreased analgesic requirement in recipient of liver transplantation from monozygotic twin - A case report.

BACKGROUND: There have been many reports about decreased analgesic requirements in liver transplant recipients compared with patients undergoing other abdominal surgery. CASE: Herein we describe a case in which a 42-year-old man underwent living donor liver transplantation from his monozygotic twin. Because innate pain thresholds may be similar in monozygotic twins, we could effectively investigate postoperative pain in the donor and the recipient. Concordant with previous reports, the recipient used less analgesic than the donor in the present study. CONCLUSIONS: Physicians caring for patients who have received liver transplantation should consider their comparatively low requirement for analgesic, to prevent delayed recovery due to excessive use of analgesic.

Perioperative risk factors of progressive chronic kidney disease following liver transplantation: analyses of a 10-year follow-up single-center cohort.

PURPOSE: The incidence of chronic kidney disease (CKD) has been increasing due to improved survival after liver transplantation (LT). Risk factors of kidney injury after LT, especially perioperative management factors, are potentially modifiable. We investigated the risk factors associated with progressive CKD for 10 years after LT. METHODS: This retrospective cohort study included 292 adult patients who underwent LT at a tertiary referral hospital between 2000 and 2008. Renal function was assessed by the e stimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease formula. The area under the curve of serial eGFR (AUCeGFR) was calculated for each patient to assess the trajectory of eGFR over the 10 years. Low AUCeGFR was considered progressive CKD. Linear regression analyses were performed to examine the associations between the variables and AUCeGFR. RESULTS: Multivariable analysis showed that older age (regression coefficient = -0.53, P < 0.001), diabetes mellitus (DM) (regression coefficient = -6.93, P = 0.007), preoperative proteinuria (regression coefficient = -16.11, P < 0.001), preoperative acute kidney injury (AKI) (regression coefficient = -14.35, P < 0.001), postoperative AKI (regression coefficient = -3.86, P = 0.007), and postoperative mean vasopressor score (regression coefficient = -0.45, P = 0.034) were independently associated with progressive CKD. CONCLUSION: More careful renoprotective management is required in elderly LT patients with DM or preexisting proteinuria. Postoperative AKI and vasopressor dose may be potentially modifiable risk factors for progressive CKD.

Symptomatic (Hypotensive) Bradycardia During Laparoscopic Living Donor Hepatectomy: Incidence and Risk Factors.

BACKGROUND: The use of a minimally invasive laparoscopic approach in living donor hepatectomy is increasing with the need for enhanced management of living donors. Hypotensive bradycardia often occurs during abdominal surgery and can be fatal without proper management. We conducted a retrospective study to investigate the incidence and risk factors of symptomatic (hypotensive) bradycardia in laparoscopic living donor hepatectomy. METHODS: Hypotensive bradycardia is defined as the heart rate below 60 beats per minute with simultaneous mean arterial blood pressure (MAP) below 65 mm Hg. Clinical characteristics of liver donors were collected and analyzed from May 2018 to July 2019. RESULTS: This study included 129 cases of living donor hepatectomy; 11 donors of open hepatectomy were excluded, and 118 donors undergoing laparoscopic hepatectomy were analyzed. Hypotensive bradycardia was shown in 27 donors. Hypertension or angiotensin receptor blocker medication were significantly related to hypotensive bradycardia. Hypotensive bradycardia occurred after incision in 22 donors, and the onset time from the incision was 7.5 minutes [first quartile (Q1) 5.75, third quartile (Q3) 11.5, range 0-25], the minimum heart rate was 48.5 beats per minute (Q1 41.5, Q3 53.25, range 25-57), and the minimum MAP was 55 mm Hg (Q1 45, Q3 57.5, range 35-63). It took 132 seconds (Q1 42, Q3 189, range 12-408) to recover MAP over 65 mm Hg. CONCLUSIONS: Hypotensive bradycardia occurred in 22.9% of the laparoscopic living donor hepatectomy cases, and 80.6% of cases occurred after incision. Thorough preoperative evaluation and close monitoring is important even in a healthy donor.

Incidence and clinical significance of hyperfibrinolysis during living donor liver transplantation.

: We evaluated the incidence and clinical significance of hyperfibrinolysis during living donor liver transplantation (LDLT) using viscoelastic coagulation tests. We retrospectively reviewed adult LDLT recipients from February 2010 to February 2015. Hyperfibrinolysis was defined when clot lysis index [LY60 = (MA - A60)/MA × 100, %] was less than 85, where A60 is the clot amplitude at 60 min after maximum amplitude (MA) occurred. Viscoelastic coagulation tests were performed six times (T1: immediately after anesthetic induction, T2: end of preanhepatic phase, T3: 1 h after anhepatic phase, T4: 5 min after reperfusion, T5: 1 h after reperfusion, and T6: 3 h after reperfusion). One hundred-ten recipients were included in final analysis. Hyperfibrinolysis was uncommon in preanhepatic phase (0% at T1 and 4.5% at T2) and aggravated during anhepatic phase and peaked immediately after reperfusion, 18% at T3 and 71% at T4. However, hyperfibrinolysis nearly disappeared 1 h after reperfusion and did not recur; 0.9% at T5 and 0% at T6. Hyperfibrinolysis was not predicted from preoperative demographics and coagulation profiles. However, the degree of coagulation profile derangements and intraoperative blood loss was greater in the hyperfibrinolysis group. During LDLT, hyperfibrionlysis frequently occurred at anhepatic phase and immediately after reperfusion, but it was resolved during postreperfusion phase.

Hyperthermia associated with biliary obstruction during living donor liver transplantation.

Intraoperative hypothermia occurs frequently, but hyperthermia is relatively rare during general anesthesia. We experienced a case of hyperthermia during living donor liver transplantation that appeared to be significantly associated with biliary obstruction. A 65-year-old male patient was diagnosed with intrahepatic cholangiocarcinoma, and living donor liver transplantation was planned after confirmation of no metastasis via intraoperative frozen biopsy. Following resection of a segment of common bile duct for frozen biopsy, the surgeon clamped the common bile duct, and the patient's body temperature increased gradually to 39.5°C. As the congested bile was drained, the body temperature decreased to the normal range. This case report suggests that when a patient develops unexplained hyperthermia during hepatobiliary surgery or in a chance of biliary obstruction, clinicians should consider bile congestion as a possible reason for hyperthermia.

Hemodynamic Implications of Carbon Monoxide (CO) and Nitrogen Oxide (NO) during Living Donor Liver Transplantation.

Carbon monoxide (CO) and nitrogen oxide (NO) affect vasodilation and cause hemodynamic change. Hemodynamic instability due to liver transplantation may result in poor prognosis of graft. This study investigated the hemodynamic implications of CO and NO levels measured using carboxyhemoglobin (COHb) and methemoglobin (MetHb) during living donor liver transplantation (LDLT). The hemodynamic instability with a pressor dose (norepinephrine equivalent) was estimated 1 hour after graft reperfusion. COHb and MetHb were used as indexes of CO and NO, and were measured using an arterial blood gas analyzer. One hundred and ten recipients who underwent LDLT from May 2011 to July 2013 were selected. Recipients were divided into high (≥ 1.9%) and low (< 1.9%) COHb groups with COHb concentrations at 5 minutes after reperfusion. Recipients were also divided into high (≥ 0.4%) and low (< 0.4%) MetHb groups with MetHb concentrations at 30 minutes after reperfusion. Data are presented as mean ± standard deviation or number (percentage). Model for End-stage Liver Disease (MELD) scores were different for the two COHb groups (low: 13.4 ± 9.0 vs. high: 19.7 ± 10.6, p < 0.001), and pressor doses adjusted by MELD scores were also different between the two COHb groups (low: 0.09 ± 0.01 µg/kg/min vs. high: 0.14 ± 0.01 µg/kg/min, p = 0.029). By contrast, pressor doses and MELD scores were not different between the two MetHb groups. In conclusion, CO rather than NO has hemodynamic implications during LDLT. Therefore, the increase in COHb during LDLT is predictive of hemodynamic instability.

Anesthetic management during the first combined heart-liver transplant performed in Korea: a case report.

Herein, we describe the anesthetic management during the first combined heart-liver transplant (CHLT) performed in Korea. Though CHLT is a rare procedure, accumulating evidence suggests that it is a feasible option for patients with coexisting heart and liver failure. A 45-year-old female patient presented with severe cardiac dysfunction requiring extracorporeal membrane oxygenation (ECMO) support and secondary congestive hepatopathy. The patient underwent consecutive heart and liver transplantation using extracorporeal circulatory devices-heart transplant with cardiopulmonary bypass, and liver transplant with peripheral ECMO. In this case report, we focus on the specific anesthetic considerations for CHLT pertaining to the challenges associated with dual pathophysiology.

A case series on simultaneous liver and kidney transplantation: do we need intraoperative renal replacement therapy?

Since the implementation of the model for end-stage liver disease (MELD) scoring system in 2002, the liver transplantation (LT) society has observed a substantial increase in the number of recipients with renal dysfunction. Intraoperative renal replacement therapy (ioRRT) has emerged as one of the solutions available to manage high-MELD score recipients; however, its usefulness has not yet been proven. To date, we have experienced five cases of simultaneous liver and kidney transplantation (SLKT). Recipients of SLKT tend to have a lower pre-transplant kidney function and the longer operation time mandates a larger amount of fluid than LT alone. Hence, anesthetic care is more prone to be challenged by hyperkalemia, metabolic acidosis, and volume overload, making ioRRT a theoretically valuable intervention. However, in all five cases, recipients were managed without ioRRT, resulting in excellent graft and patient survival. As such, in this case series, we discuss current issues about ioRRT and SLKT.

Comparison of intrathecal morphine and surgical-site infusion of ropivacaine as adjuncts to intravenous patient-controlled analgesia in living-donor kidney transplant recipients.

INTRODUCTION: This prospective observational study compared the postoperative analgesic effectiveness of intrathecal morphine (ITM) and surgical-site infusion (SSI) of ropivacaine as adjuncts to intravenous (IV) patient-controlled analgesia (PCA) (fentanyl) in living-donor kidney transplant recipients. METHODS: Patients undergoing living-donor kidney transplantation who received ITM or SSI in addition to IV PCA were included. Rescue analgesia was achieved with IV meperidine as required. The primary outcome, measured using the Numeric Pain Rating Scale (NRS), was pain at rest and when coughing. Patients were assessed for 48 hours after surgery. RESULTS: A total of 53 patients (32 ITM, 21 SSI) were included in the study. The ITM group showed significantly lower NRS scores, at rest and when coughing, for up to 12 and eight hours. NRS scores were comparable between the groups at other times. The ITM group had significantly less postoperative systemic opioid requirement in the first 24 hours, but there was no significant difference between the systemic opioid consumption of the groups on postoperative Day 2. In the ITM group, 3 (9.4%) patients presented with bradypnoea and 1 (3.1%) with excessive sedation in the first 12 postoperative hours. More patients in the ITM group developed pruritus requiring treatment during the first 24 hours. There were no differences between the groups in other outcomes (e.g. nausea/vomiting, change in pulmonary or kidney functions). CONCLUSION: Compared with SSI, ITM reduced immediate postoperative pain and IV opioid consumption on postoperative Day 1 after living-donor kidney transplantation, but at the cost of increased pruritus and respiratory depression.

Liver transplantation in Jehovah's Witnesses: two cases report.

Liver transplantation is especially challenging in patients who are Jehovah's Witnesses because their religious beliefs prohibit the receipt of blood products. We present two cases of living donor liver transplantation performed in adult Jehovah's Witnesses in South Korea without the use of blood products. In the first case, preoperative erythropoiesisstimulation therapy increased hemoglobin levels from 8.1 to 13.1 g/dl after 9 weeks. In the second case, hemoglobin levels increased from 7.4 to 10.8 g/dl after 6 months of erythropoiesis-stimulation therapy. With the combination of acute normovolemic hemodilution, intraoperative cell salvage, and use of transfusion alternatives, liver transplantation was successfully performed without transfusion of blood products.

Preoperative depressed mood and perioperative heart rate variability in patients with hepatic cancer.

STUDY OBJECTIVE: How perioperative heart rate variability (HRV) indices differ according to the anxiety or depressed mood of patients scheduled to undergo a major surgical procedure for cancer. DESIGN: Prospective observational study. SETTING: Operating room. PATIENTS: Forty-one male patients between 40 and 70 years of age with hepatocellular carcinoma were included in the final analysis. INTERVENTIONS: HRV was measured on the day before surgery (T1), impending anesthesia (T2), and after anesthetic induction (T3). Preoperative anxiety and depressed mood of all patients were evaluated using the State-Trait Anxiety Inventory and Self-Rating Depression Scale (SDS). MEASUREMENTS AND RESULTS: HRV was significantly different among T1, T2, and T3. At T2, high frequency (HF) (normalized units of HF [nuHF]) was decreased and low frequency (LF) (normalized units of LF) and LF/HF were increased compared with those at T1 and T3. In the subgroup analysis between high and low SDS groups, high SDS group showed significantly decreased nuHF (P = .035), increased nuLF (P = .039), and increased LF/HF (P = .020) compared to low SDS group at T1. However, these values at T2 and T3 were not different between 2 groups. In analysis within the groups, low SDS group showed significant differences in nuHF, nuLF, and LF/HF among T1, T2, and T3 (P < .05, respectively), but no changes in these values were observed in high SDS group among the 3 different time points. CONCLUSIONS: HRV decreased significantly immediately before anesthesia and recovered to baseline with anesthetic induction. Preoperative, more depressed patients showed increased sympathetic tone at baseline and blunted response to impending anesthesia on the HRV measurements.