[Acid-base disturbances during liver transplantation].

UNLABELLED: Objective of the study is to assess the contribution of different factors in the development of acid-base disturbances at the stages of liver transplantation. MATHERIALS AND METHODS: The analysis of right lobe relative liver transplantation was held in 86 recipients. 22 patients corresponded to ASA III (group 1), ASA IV - 50 patients (group 2), and ASA V - 14 patients (group 3). Blood samples were studied by pH, SB, lactate, pCO2 at the stages: up to the beginning, before v. cava inferior cross-clamping, before blood flow launch, on the 1st minute after blood flow launch, 5 min after blood flow launch. 1 hour after the blood flow launch, 2 hours after blood flow launch, at the end of operations. Cardiac index and oxygen delivery were also estimated RESULTS: The preliverless stage was characterized by a decrease in pH, SB. BE and increased lactate, oxygen delivery slightly reduced due to the reduction of oxygen blood capacity, cardiac index remained within the normal range. During liverless period, the growth rate of lactate was different in all three groups, DO2 was below the norm, CI - on the lower bound of the norm. Blood flow launch was accompanied by a peak values of pH, SBC, BE, lactate and increased pCO2. CONCLUSIONS: The main factor in the development of metabolic acidosis during preliverless stage is lactate growth as a consequence of decreased hepatic lactate clearance and blood loss. During liverless period the most significant impact contributes to reduced cardiac output, which, together with reduced oxygen blood capacity leads to a decrease in tissue DO2. Increased production of lactate, together with a decrease in its clearance due to liver shutdown from the bloodstream leads to higher rates of lactate growth in this period. When starting the blood flow in addition to the release of acidic substances, growth of endogenous CO2 leads to the peak pH values.

[To the issue of postreperfusion syndrome predictors in orthotopic liver transplantation (OLT)].

UNLABELLED: The aim of the study is revelation of postperfusion syndrome (pPS) predictors in orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Was conducted a retrospective analysis of anesthesia maintainance protocols during orthotopic liver transplantation in 261 patients aged from 6 months to 60 years. Investigated the effect of various factors on the development of PPS by the application of methods of non-parametric statistics. RESULTS: Significantly more frequent development of the PPS is noted in the age group from 3 to 18 years (up to 30% of patients). In recipients older than 18 years the frequency of the development of the PPS does not depend on age, with an average of 14%. The development of the PPS does not depend on the recipient sex, the nature of the pathology which served as an indication to the OTP, the initial severity of the state, type of OTP (living related donor or cadaveric transplantation, primary or re-transplantation), the transplant warm ischemia duration, use, or the lack of venous-venous bypass, metabolic status of the patient. The obtained results do not contradict to the data of foreign publications. Among parameters available for screening, predictor of PPS was not detected.

[Anesthetic maintenance of renal transplantation in children].

For many children with severe renal excretory dysfunction, renal transplantation is the sole method of life prolongation. The purpose of the investigation was to analyze the specific features of anesthetic maintenance of transplantation of related and cadaver kidney at 1 to 5 years. The investigation involved a detailed analysis of the specific features of 101 anesthesias made in children aged 1 to 16 years (mean 9.6+/-4.87 years) during transplantation of kidneys from corpses and apparently healthy relatives. The duration of surgery and anesthesia was 5.6+/-1.00 and 7.6+/-1.42 hours, respectively. Operations were made under balanced general anesthesia using a low-flow inhalational isoflurane or sevoflurane (0.5-2.0 MAC) technology. After inclusion of a graft into the bloodstream, a plasmapheresis procedure was initiated in 1-1.5 circulating blood volumes. All the children underwent invasive hemodynamic monitoring: the radial artery and internal jugular vein were catheterized. In 19 cases, the pulmonary artery was catheterized using a Swan-Ganz catheter. In children, the initial period of anesthesia during renal transplantation was marked by a drastic hemodynamic instability tended for hypotension and significant tachycardia in the presence of marked hypovolemia (central venous pressure = 0+/-2.0 mm Hg). The major component of infusion therapy was freshly frozen plasma (up to 50% of the volume). Inclusion of a cold renal graft into systemic circulation and washout of residues of preservative solution and necrobiolysis products from it were accompanied by a 0.5-1.3 degrees C temperature reduction and progression of metabolic acidosis. Safe and successful anesthetic maintenance of renal transplantation in children requires an obligatory informative invasive hemodynamic monitoring, continuous laboratory screening, and knowledge of stage-specific features. Continuous plasmapheresis by means of a plasma filter is preferred.

[A laryngeal mask as an instrument of ventilation support during regional anesthesia].

When the duration of limb segment replantation is more than 8-10 hours under nerve block anesthesia, prominent are the factors of the patient's lassitude and fatigue caused by position discomfort, the elimination of which and the possibility of uncontrolled motor activity of the patient require deep sedation or his/her unconsciousness. In this connection, a laryngeal mask (LM) has proven to be a convenient and reliable alternative to an endotracheal tube, which allows tracheal intubation to be avoided in most cases. Our clinical observations of the course of anesthesia in patients during carpal segment replantations of 14 hours or more in duration have demonstrated that the LM reliably ensures upper airways patency, adequate ventilation, and gas exchange throughout the surgery. An algorithm of switching patients to different assisted ventilation modes to rapidly restore adequate ventilation and gas exchange if drug-induced respiratory distress occurs during regional anesthesia has been tested during 120 emergency and elective anesthesias. Indications for the clinical use of a LM in patients who need emergency reparative operations using microsurgical techniques are warranted. Various actions of an anesthesiologist are proposed while using a LM in patients with limb segment replantation.

[Clinical experience in using isoflurane, sevoflurane, and total intravenous anesthesia during visceral transplantation].

Based on 256 anesthesias, the authors comparatively studied the results of total intravenous anesthesia (TIVA) with neuroleptic analgesics and inhalational low- and minimal flow anesthesia with isoflurane in the anesthestic support of major operations on the liver. Both sevoflurane and isoflurane may be widely used during long and traumatic operations on the liver since the agents are distinguished by a low hepatotoxicity, the absence of pharmacological activity of their metabolism, a rapid elimination from the body in a virtually unchanged form. The use of sevoflurane and isoflurane in the low and minimal flow modes can substantially reduce the pharmacological load with opiates and myorelaxants, which is particularly important in patients with liver diseases and these modes have some advantage over TIVA during which the consumption of myorelaxants and neuroleptic analgesics has proved to be significantly higher. The minimal flow (0.4-0.5 l/min) mode uses mostly few inhalation anesthetics. The use of seroflurane reduces the period of spontaneous breathing recovery to a greater extent, activates the patient more rapidly, and substantially reduces the risk of iatrogenic complications after long and traumatic operations associated with visceral transplantation.

[Hemodynamic disorders in liver transplantation and their correction].

To study the pre- and intraoperative causes of hemodynamic disorders at the basic stages of liver transplantation in adult recipients, case histories and anesthesia protocols were analyzed in detail in 15 recipients of the cadaveric liver (Group 1) and 60 recipients of a liver portion taken from a living relative donor (Group 2). The patients' preoperative status, the etiology of the disease, the pattern and scope of preoperative preparation and examination, the cause of anesthesia, the volume, pattern, and rate of infusion were studied. Particular emphasis was placed on the presence of pathophysiological prerequisites and various intraoperative factors, which are causes of hemodynamic disorders. Orthotopic transplantation of the liver was performed under generalized balanced anesthesia whose major components were the inhalational anesthetics isoflurane and sevoflurane (89.3%) or total intravenous anesthesia based on neuroleptic anesthetics (10.7%). The main causes of hemodynamic disorders were the patients' severe baseline condition, anemia, ascitis, intoxication, encephalopathy, and the specific features of a surgical intervention, blood loss, heavy plasma and perspiration losses, water-electrolyte balance impairments, vein-vein shunt and reperfusion syndrome. Operations of extraordinary duration (longer than 15-20 hours) required higher plasma compensation volumes (36-52 ml/kg). Severest hemodynamic disorders were observed in patients admitted to hospital for emergency transplantation of the cadaveric liver. These patients who are to undergo transplantation are outside hospital in most cases, which is why any operation should be regarded in them as an emergency one made in patients who are in a very severe state (ASA IV-VE).

[Hemodynamic changes during anesthesia in orthotopic liver transplantation in 1-5-year-old children]. / Izmeneniia gemodinamiki vo vremia anestezii pri ortotopicheskoi transplantatsii pecheni u detei v vozraste 1-5 let.

The anesthetic management of orthotopic hepatic transplantation (OHT) was analyzed in 49 children aged 1 to 15 years. Ten protocols of anesthesia implemented in small-age children (1 to 5 years) were analyzed in detail. The mean age of children (6 girls, 4 boys), operated on in 2002-2004, was 3.0 +/- 2.7 years; their mean weight was 13.6 +/- 4.17 (9-22) kg. The purpose of the case study was to study the dynamics of the cardiovascular system and the pattern of hemodynamic impairments accompanying the anesthetic course in OHT from a living related donor. All surgeries were made under balanced general anesthesia: induction - midazol (0.04 +/- 0.01 mg/kg), cetamine (2.77 +/- 0.64 mg/kg), phentanile (3.1 +/- 0.21 mg/kg), myorelaxation--pipecuronium bromide (arduan) (80.3 +/- 11.44 microg/kg). Low-flow inhalation by isofluoran -0.8-2.0 ALC%, minimal-flow (0.7-1.6 MAC), was used.

[Transplantation of the right hepatic lobe from an alive relative donor]. / Transplantatsiia pravoi doli pecheni ot zhivogo rodstvennogo donora.

The use of relative donors in the transplantation of the liver has shown a good performance as an alternative line in its orthotopical grafting. Shortage of donor organs actively stimulates the development of relative transplantation. The main problem of relative hepatic transplantation is the limited capacity of obtaining a required mass of a hepatic graft for obese recipients. To settle this problem, the Russian Surgery Research Center, Russian Academy of Medical Sciences, has developed an original safe procedure for obtaining the right lobe of the liver from an alive relative donor and for implanting it in a recipient. In November 1997 to October 2001, transplantation of the right hepatic lobe from an alive relative donor was made in 23 recipients (10 males and 13 females aged 9 to 55 (mean 22.3 +/- 3.1) years. Their body weight was 24 to 80 (mean 51.4 +/- 3.0) kg. Indications for surgery were as follows: hepatic cirrhosis (HC) at the end stage of the Wilson-Konovalov disease (n = 10), primary sclerotic cholangitis (n = 4), HC of viral etiology (n = 3), Bailer's disease (n = 2), primary biliary HC (n = 2), HC in the presence of alpha 1-antitrypsin deficiency (n = 1), and secondary biliary HC (n = 1). The donors of the right lobe of the liver were recipients' mothers in 9 cases, their fathers in 6 cases, sisters in 2 cases, sons in 1 cases, their daughter, brother, aunt, cousin in 1 case each. The donors' age ranged from 19 to 49 (mean 37.9 +/- 1.4) years. The donors underwent right hemihepatectomy, complications were absent in them. There were early mortality among the recipients. Two patients died in the late postoperative period. The remaining 21 recipients were survivors and followed up for 1 to 48 (mean 14.9 +/- 2.9) months. Their life quality was good. The use of the right lobe of the liver from an alive relative donor is the optimum alternative to transplantation of the cadaverous liver and partially compensates the shortage of donor organs for children, adolescents, and adults.

[Anesthesia during liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

Different methods and components of anesthesia during operations in donors and recipients were studied by using the experience in maintaining anesthesia during 39 relative and 7 cadaveric hepatic transplantations. The experience in using epidural anesthesia and total intravenous anesthesia at the donor stage of hepatic lobar transplantation was comparatively analyzed. Combined epidural anesthesia (CEA) may be used during long-term and traumatic operations dealing with hepatic lobectomy in a relative donor since it is noted for low hepatotoxicity and no drastic hemodynamic exposures. CEA can substantially reduce pharmacological loading with opioids or myorelaxants, which is particularly important in taking the lobe of the liver. This reduces the recovery period of adequate own respiration, activates a patient more rapidly, substantially reduces the risk for postoperative iatrogenic complications. Balanced general anesthesia whose major component is inhalational anesthesia with isoflurane is the method of choice in performing an operation in the recipient. The use of isoflurane in the minimal-flow mode is cost-effective and safe. When anesthesia is performed in the recipient, it is necessary to take in account drastic hemodynamic pattern changes at the liverless stage during vein-venous bypass surgery, including the liver into systemic circulation, and the likelihood of development of significant reperfusion and concomitant metabolic and coagulative disorders.

[Experience in the clinical use of intravenous hypnotic pofol (propofol) in anesthesias of different duration]. / Opyt klinicheskogo ispol'zovaniia vnutrivennogo gipnotika pofol (propofol) pri anesteziiakh razlichnoi prodolzhitel'nosti.

A new anesthetic pofol is characterized by predominantly hypnotic effect; it is a pharmacological analog of a well-known drug diprivan (propofol). The drug was used in 60 anesthesias for bronchoscopic manipulations and cardiosurgical operations. Its effects on hemodynamics, gas exchange, and reactions during induction and after anesthesia were evaluated. The present findings and results of previous clinical trials of diprivan indicate identity of pofol and diprivan. Clinical course of induction and anesthesia and hemodynamic reactions and effects on the respiratory system of patients were virtually the same. Pofol is well tolerated by the patients, its allergenic activity is low, it is rapidly metabolized and causes virtually no side effects. Positive results of clinical trials of pofol recommend it for clinical use.

[Clinical experience with low- and minimal-flow isoflurane in extensive resections of the liver and liver transplantation]. / Klinicheskii opyt ispol'zovaniia izofliurana v rezhimakh low- i minimal-flow pri obshirnykh rezektsiiakh i transplantatsii pecheni.

A comparative study was performed of general balanced anesthesia on the basis of neuroleptic analgesia (NLA) and inhalation low- and minimal-flow anesthesia with isoflurane in anesthesiological management of extensive operations on the liver. A total of 75 anesthesias were conducted. Because of low hepatotoxicity, absence of its metabolites' pharmacological activity, fast elimination from the body unchanged, isoflurane is effective in long and traumatic operations on the liver. Low-flow isoflurane significantly lowers pharmacological load with opiates, myorelaxants which is essential in patients with hepatic diseases. This leads to more rapid recovery of adequate spontaneous respiration and activation of the patient in low risk of postoperative iatrogenic complications.

[The anesthesiological aspects of the support for endoscopic manipulations on the tracheobronchial tree]. / Anesteziologicheskie aspekty obespecheniia éndoskopicheskikh manipuliatsii na trakheobronkhial'nom dereve.

A characteristic feature of anesthesia for bronchoscopic manipulations is traumatism of the interventions in highly reflexogenic areas, severity of the clinical status, unknown duration of the examination, and necessity of immediate alteration of the type and scheme of ventilation during the examination. These problems impede the choice of adequate anesthesia. Drugs used in bronchology must be highly reliable and ensure effective anesthesia, the effect should not be long, they should be rapidly metabolized, and induce no post-medication effects. Ventilation is carried out under conditions of the respiratory contour which is not constantly hermetic, through a long metal tube, with constant or temporary obturation of one lung, etc. Modern criteria for a patient's safety require reliable and informative monitoring during anesthesia. The principles of choosing an anesthesia, new drugs, and modifications of ventilation support in anesthesia for bronchoscopic examinations are discussed.

[The prevention of thrombus formation and the improvement of the blood rheological properties during operations with a microsurgical technic. I. The possibilities for using acelysin--an acetylsalicylic acid derivative]. / Profilaktika tromboobrazovaniia i uluchshenie reologicheskikh svoistv krovi pri operatsiiakh s mikrokhirurgicheskoi tekhnikoi--I. Vozmozhnosti ispol'zovaniia atselizina--proizvodnogo atsetilsalitsilovoi kisloty.

Changes in the blood clotting system and rheology were studied in 39 patients during reconstructive operations making use of microsurgical methods. Effects of various doses of water soluble acelysine, an acetylsalicylic acid preparations (DL-lysine acetylsalicylate and glycine) have been evaluated during surgery and the immediate postoperative period. Clinical and laboratory changes in blood coagulation were determined at different doses (1000, 500, and 250 mg). Even in low doses (3.94 +/- 0.25 mg/kg) acelysine ensured chronometric and structural hypocoagulation as early as 1 h after dosed infusion and throughout the entire intervention, preventing thrombosis of microvascular anastomoses. Administration of acelysine in doses higher than 250 mg is not recommended, because higher doses involve the risk of hypocoagulation complications.

[The anesthesiological support for limb segment replantations (20 years' experience)]. / Anesteziologicheskoe obespechenie replantatsii segmentov konechnostei (20-letnii opyt).

Anesthesias for urgent replantations of the limb segments in 1980-1998 are analyzed. A retrospective analysis of case histories and protocols of anesthesia of patients aged 16-64 years is carried out. Specific features of anesthesia for surgery of this kind are demonstrated. The authors suggest an algorithm of preoperative treatment of patients, determined by the severity of injury, and discuss the choice of anesthesia: variants of regional anesthesia, balanced anesthesia based on conduction blocking, and balanced anesthesia with forced ventilation of the lungs. Special attention is paid to components of anesthesia which regulate adequate bloodflow in revascularized segments of the limbs: infusion-transfusion therapy with attaining the hypervolemic hemodilution, maintenance of thermal homeostasis, prevention of "toxic shock" during incorporation of the replanted segment into the bloodflow, and strategy of patient's awakening after long operation and anesthesia.

[The anesthesiological support of liver transplantation]. / Anesteziologicheskoe obespechenie transplantatsii pecheni.

The choice of anesthesia for a high risk operation, orthotopic transplantation of the liver (OTL), is discussed. The authors propose a protocol of anesthesia for OTL. For induction anesthesia, intravenous drugs should be preferred; the liver-free stage of the operation is carried out under anesthesia with a closed isoflurane contour, and the initial metabolic disorders of patients are corrected. When the bloodflow is let in the transplanted organ, intravenous drugs (ketamine, phentanyl, and benzodiazepines) should be administered in order to reduce the vasodilating effect of isoflurane and vasopressors for preventing relative hypovolemia. At the final stage of anesthesia, isoflurane is used. Before transporting the patient into intensive care ward, phentanyl in a dose of 1.5-3 micrograms/kg was injected, because of rapid elimination of isoflurane and awakening of the patient. This protocol maintained the hemodynamics and the major metabolic parameters at the optimal level.

[Orthotopic liver transplantation]. / Ortotopicheskaia transplantatsiia pecheni.

Orthotopic liver transplantation is the only method of choice for many severe liver diseases with poor prognosis. The development of liver transplantation programmes is based on medical science achievements and high technology in surgery, anesthesiology and perfusiology. The experience of the Surgery Research Center, Russian Academy of Medical Sciences, made it possible to obtain positive results of liver transplantation and posttransplantation management. This in turn provided longer survival for 80% of recipients. At the same time the mortality of potential recipients was 60.4%, which is due to the greater shortage of donor organs and which is the main problem in the development of organ grafting in Russia. The fact that there is a high proportion of children who are recipients for the donor's liver requires that liver transplantation from living related donors should be developed.

[Experience in the use of a benzodiazepine antagonist, flumazenil]. / Opyt ispol'zovaniia antagonista benzodiazepinov--flumazenila.

The efficacy of midazolam (0.071 +/- 0.006 microgram/kg) inactivation by flumazenil, a direct antagonist of benzodiazepines, was assessed in 20 patients during local and regional anesthesia. The hemodynamic values were assessed and a complex of psychological tests used. A single intravenous injection of flumazenil in a dose of 0.2 mg (2.8 +/- 0.41 micrograms/kg) resulted in a smooth an reliable arrest of benzodiazepine effect and effective repair of the main psychomotor reactions. Reversion of benzodiazepine effect is possible after an hour, which may require repeated injection of flumazenil.