The effects of desflurane and propofol-remifentanil on postoperative hepatic and renal functions after right hepatectomy in liver donors.

Various volatile anesthetics have been used in hepatectomy in living donors, and their effects on major organs have been extensively evaluated. However, the impact of total intravenous anesthesia (TIVA) on postoperative liver and renal functions after large liver resections has been less extensively investigated than that of volatile agents. The aim of this study was to compare the postoperative hepatic and renal functions between volatile anesthesia with desflurane and TIVA with propofol-remifentanil in living donors undergoing right hepatectomy. Seventy adult patients were randomly allocated into 2 groups: the desflurane group (n = 35) and TIVA group (n = 35). Aspartate aminotransferase, alanine aminotransferase, prothrombin time (PT), albumin, total bilirubin (TB), blood urea nitrogen (BUN), creatinine (Cr), BUN/Cr ratio, estimated glomerular filtration rate (GFR), platelet count, and hemoglobin levels were analyzed in the preoperative period, immediately after the operation, and on the first, second, third, fifth, seventh, and thirtieth postoperative days (PODs). Most of the liver function test results were not significantly different between the 2 groups. However, PT (international normalized ratio) and TB were significantly greater on POD 5 in the TIVA group. Among the renal function tests, Cr was significantly higher and estimated GFR was significantly lower on POD 1 in the TIVA group. The platelet counts and hemoglobin levels were similar between the 2 groups. In conclusion, the results of our study suggest that living related donors for liver transplant may have a better outcome following anesthesia with desflurane. However, further testing will be necessary to prove this hypothesis.

Peripheral arteriovenous malformations with a dominant outflow vein: results of ethanol embolization.

OBJECTIVE: To assess retrospectively the treatment results of ethanol embolization of peripheral arteriovenous malformations (AVMs) with a dominant outflow vein (DOV). MATERIALS AND METHODS: Nineteen patients who had peripheral AVMs with a DOV were enrolled in this study (mean age, 29.7 years; range, 15-42 years). Fifty-one ethanol embolizations (mean, 2.7; range, 1-8) were performed by direct puncture (n = 29), the transarterial approach (n = 13), the transvenous approach (n = 5), or a combination of methods (n = 4) under general anesthesia. Coil and/or core-removed guide wire embolization of the DOV or another flow occlusion technique (i.e., use of an external pneumatic pressure cuff) to achieve vascular stasis were required in all patients during ethanol embolization. Clinical follow-up (mean, 22.2 months; range, 1-53 months) was performed for all patients, and imaging follow-up (mean, 22.1 months; range, 2-53 months) from the last treatment session was performed for 14 patients. The therapeutic outcome (cure, improvement, no change, or aggravation) was assessed according to the clinical response and the degree of devascularization at angiography. RESULTS: Ethanol embolization was considered as an effective procedure in all patients. Thirteen (68%) of 19 patients were cured and six displayed improvement. Three of six patients with improvement needed further treatment sessions for residual AVMs. Four patients (21%) experienced a total of eight complications. Five complications (three events of a distal embolism and one event each of a urinary bladder necrosis and a brain infarct related to the accidental cannulation of the common carotid artery during insertion of the Swan-Ganz catheter) were major and three complications (skin necrosis) were minor. CONCLUSION: Peripheral AVMs with a DOV can be effectively treated with a high cure rate by the use of ethanol embolization alone or in conjunction with the use of coil and/or core-removed guide wire embolization.

Intravascular injection in lumbar medial branch block: a prospective evaluation of 1433 injections.

BACKGROUND: The successful outcome and validity of lumbar medial branch block (MBB) are largely dependent on technique accuracy. Intravascular uptake of injectate causes a false-negative response to block and is associated with various possible complications. In the current study, we prospectively evaluated the incidence of, and the factors associated with, intravascular injection during block. In addition, we assessed the efficiencies of generally accepted safety measures, such as preinjection aspiration and intermittent fluoroscopy to avoid intravascular injections. METHODS: We prospectively examined 1433 lumbar MBBs in 456 patients performed by seven physicians. Aspiration test, spot radiography, and contrast injection under real-time fluoroscopic visualization were performed sequentially without repositioning the needle. Incidences of blood flashback and the presence of intravascular contrast spread on spot radiographic images and during real-time fluoroscopy were checked. The factors studied for intravascular injection included physician experience, patient age and sex, needle gauge, and block spinal level. RESULTS: No specific factors were found to affect the incidence of intravascular uptake during block. The overall incidence of intravascular uptake was 6.1% per nerve block (88/1433), and 30 of these were predicted by preinjection aspiration (sensitivity = 34.1%) and 52 by spot radiography (sensitivity = 59.1%). CONCLUSIONS: The aspiration test with or without spot radiography frequently missed the intravascular uptake of contrast during lumbar MBBs. We strongly advocate the use of real-time fluoroscopy during contrast injection to increase diagnostic and therapeutic value and to avoid possible complications.

The effects of prehydration on the properties of cerebrospinal fluid and the spread of isobaric spinal anesthetic drug.

BACKGROUND: In a two-part clinical study, we investigated the effect of the administration of fluids "prehydration" on the physical properties of cerebrospinal fluid (CSF) and intrathecal spread of local anesthetics. METHODS: First, in the clinical spinal anesthesia study, 68 patients were allocated randomly into the prehydration or nonprehydration groups. One group was prehydrated with 10 mL/kg of lactated Ringer's solution, and spinal anesthesia was performed with 12 mg of 0.5% isobaric tetracaine in all patients at the lumbar level. The arterial blood pressure, heart rate, and sensory block level were assessed. Second, in a magnetic resonance image study, 24 male volunteers were enrolled. CSF motion variables were measured after infusion of 10 mL/kg of lactated Ringer's solution to examine the net flow and volume displacement of the CSF at the L2-3 disk level. RESULTS: In the clinical study, there were no significant differences in arterial blood pressure, heart rate, and median peak sensory block level between the two groups, but the median time to reach peak sensory block level (26.4 +/- 15.7 vs 16.5 +/- 9.2 min, P < 0.05) was longer in group P. In posthydration magnetic resonance images, the CSF regurgitant fraction (caudal flow) was significantly increased after hydration, but the stroke volume, absolute stroke volume, mean flux, stroke distance, and mean velocity in the cranial direction were significantly decreased. CONCLUSIONS: Rapid crystalloid prehydration can affect CSF flow in the lumbar region, reducing cephalic spread of 0.5% isobaric tetracaine and delaying the time to reach the peak sensory level.

Effects of gender on white blood cell populations and neutrophil-lymphocyte ratio following gastrectomy in patients with stomach cancer.

Alterations of absolute number or percentage of circulating white blood cell (WBC) subsets are associated with psychological and physical stress. Gender effects on the changes of circulating WBC subsets following surgical treatment have not been determined. Therefore, the current study aimed to determine whether circulating neutrophils, lymphocytes and monocytes, and neutrophil-lymphocyte ratio (N/L) are different following major surgery according to the gender. We studied 409 male patients and 212 female patients who underwent total or subtotal gastrectomy due to stomach cancer, from 1 January to 31 December in 2005. The WBC count and percentage of its subsets were obtained from database and N/L was directly calculated from the full blood count preoperatively, immediate postoperatively, and postoperative day 1, 3, 5 in a retrospective manner. Compared to preoperative values, neutrophilia, lymphopenia, monocytopenia, and increased N/L were associated with gastrectomy in all patients. In the comparison study between genders, there were significantly increased proportion of neutrophils, decreased lymphocytes and monocytes, and higher N/L in female patients than in male patients after gastrectomy. These findings indicate that female patients showed more immune-compromised response to gastrectomy than male patients.

Combination of antiemetics for the prevention of postoperative nausea and vomiting in high-risk patients.

It was previously reported that the Korean predictive model could be used to identify patients at high risk of postoperative nausea and vomiting (PONV). This study investigated whether PONV in the high-risk and very high-risk patients identified by the Korean predictive model could be prevented by multiple prophylactic antiemetics. A total of 2,456 patients were selected from our previous PONV study and assigned to the control group, and 374 new patients were recruited consecutively to the treatment group. Patients in each group were subdivided into two risk groups according to the Korean predictive model: high-risk group and very high-risk group. Patients in the treatment group received an antiemetic combination of dexamethasone 5 mg (minutes after induction) and ondansetron 4 mg (30 min before the end of surgery). The incidences of PONV were examined at two hours after the surgery in the postanesthetic care unit and, additionally, at 24 hr after the surgery in the ward, and were analyzed for any differences between the control and treatment groups. The overall incidence of PONV decreased significantly from 52.1% to 23.0% (p< or =0.001) after antiemetic prophylaxis. Specifically, the incidence decreased from 47.3% to 19.4% (p< or =0.001) in the high-risk group and from 61.3% to 28.3% (p< or =0.001) in the very high-risk group. Both groups showed a similar degree of relative risk reductions: 59.0% vs. 53.8% in the high-risk and very high-risk groups, respectively. The results of our study showed that the antiemetic prophylaxis with the combination of dexamethasone and ondansetron was effective in reducing the occurrence of PONV in both high-risk and very high-risk patients.

Can peripheral venous pressure be an alternative to central venous pressure during right hepatectomy in living donors?

The safety of living donors is a matter of cardinal importance in addition to obtaining optimal liver grafts to be transplanted. Central venous pressure (CVP) is known to have significant correlation with the amount of bleeding during parenchymal transection and many centers have adopted CVP monitoring for right hepatectomy. However, central line cannulation can induce some serious complications. Peripheral venous pressure (PVP) has been suggested as a comparable alternative to CVP. The aim of this study was to determine whether a clinically acceptable agreement or a reliable correlation between CVP and PVP exist and if CVP can be replaced by PVP in living liver donors. A central venous catheter was placed through the right internal jugular vein and a peripheral venous catheter was inserted at antecubital fossa in the right arm. CVP and PVP were recorded in 15-minute intervals in 50 adult living donors. The paired data were divided into 3 stages: preparenchymal transection, parenchymal transection, and postparenchymal transection. A total of 1,430 simultaneous measurements of CVP and PVP were recorded. Overall, the PVP, CVP, and bias were 7.0+/-2.46, 5.9+/-2.32, and 1.16+/-1.12 mmHg, respectively. A total of 88.9% of all measurements were clinically within acceptable limits of bias (+/-2 mmHg). Regression analysis showed a high correlation coefficient between PVP and CVP (r=0.893; P<0.001) and the limits of agreement were -1.03 to 3.34 overall. In conclusion, frequencies of differences, bias, correlation coefficient, and limits of agreement between PVP and CVP remained relatively constant throughout the operation. Therefore, PVP measurement in the arm can be an alternative to predict CVP and further, obviate central venous catheter-related complications in living liver donors.

The changes in coagulation profile and epidural catheter safety for living liver donors: a report on 6 years of our experience.

The use of epidural catheters has been a subject of active debate in living liver donors because of the possible postoperative coagulation derangement and the subsequent risk of epidural hematoma. The aim of this study was to evaluate the safety of epidural catheters in relation to the changes in coagulation profile based on a review of previously published literature and the results of our 360 donors. In both the literature and in our cases, platelet count, prothrombin time (PT), and activated partial thromboplastin time (aPTT) in cases of heparin administration showed significant changes (P < 0.05), especially after right lobectomy. Platelet count reached its nadir on postoperative day (POD) 2-3, while PT and aPTT reached their peaks on POD 1-2 and at the end of the operation, respectively. In our donors, the ranges of platelet count, PT, and aPTT for the first 3 PODs were 54-359 x10/microL, 0.99-2.38 international normalized ratio (INR), and 25.9-300 seconds, respectively, and of note, 5 donors (1.4%) had a platelet count of <80 x 10/microL and 9 donors (2.5%) had a PT of >2.0 INR. Epidural catheterizations were performed in 242 donors, and the catheters were removed on POD 3-4 in 177 donors (73.1%). Mean (range) of platelet count, PT, and aPTT on the day of catheter removal were 168.4 +/- 42.9 (82-307) x 10/microL, 1.33 +/- 0.18 (0.99-1.93) INR, and 40.9 +/- 4.8 (32.0-70.6) seconds, respectively. No epidural hematoma was observed in this study. In conclusion, the discreet use of epidural catheters in live liver donors, in spite of postoperative coagulation derangements, appears to be safe regardless of the type of hepatectomy performed.

A korean predictive model for postoperative nausea and vomiting.

Postoperative nausea and vomiting (PONV) is one of the most common and distressing complications after surgery. An identification of risk factors associated with PONV would make it easier to select specific patients for effective antiemetic therapy. We designed a case-controlled study to identify the risk factors for PONV in 5,272 surgical patients. At postoperative 2 and 24 hr, patients were visited and interviewed on the presence and severity of PONV. Thirty nine percent of patients experienced one or more episodes of nausea or vomiting. Five risk factors were highly predictive of PONV: 1) female, 2) history of previous PONV or motion sickness, 3) duration of anesthesia more than 1 hour, 4) non-smoking status, and 5) use of opioid in the form of patient controlled analgesia (PCA), in the order of relevance. The formula to calculate the probability of PONV using the multiple regression analysis was as follows: P (probability of PONV)=1/1+e(-Z), Z=-1.885+0.894 (gender)+0.661 (history)+0.584 (duration of anesthesia)+0.196 (smoking status)+0.186 (use of PCA-based opioid) where gender: female=1, male=0; history of previous PONV or motion sickness: yes=1, no=0; duration of anesthesia:more than 1 hr=1, less than or 1 hr=0; smoking status: no=1, yes=0; use of PCA-based opioid: yes=1, no=0.

Differences of perioperative liver function, transfusion, and complications according to the type of hepatectomy in living donors.

Numerous living donor hepatectomy are being performed safely. However, donors are still exposed to various complications including hepatic failure. We examined the donor's potential risk and morbidity depending on the type of hepatectomy: left lateral segmentectomy (group LLS, n = 30), left lobectomy (group LL, n = 15), and right lobectomy (group RL, n = 128). The charts and computerized hospital data of 173 donors from March 2000 to September 2003 were retrospectively reviewed. We analyzed liver function tests (LFT), RBC transfusion, and complications. Although the graft weight was greatest, and surgical and anesthetic times were longest in the group RL, there were no significant differences in postoperative hospital stay, RBC transfusion, and major complications among the groups. However, minor complications were significantly higher in group RL than group LLS. Postoperative prothrombin time and total bilirubin were significantly higher in the group RL than the other groups (P < 0.05). Living donor hepatectomy is relatively safe, and it is evidenced by rapid recovery of LFT and low occurrence of major complications. However, noticeable depression of LFT and frequent minor complications occur after hepatectomy, especially RL.