Right ventricular ejection fraction during orthotopic liver transplantation: does anesthetic technique make a difference?

PURPOSE: The objective of this study is to evaluate the right ventricular ejection fraction (RVEF) during orthotopic liver transplantation (OLT) under 2 different anesthetic regimens: propofol vs isoflurane anesthesia. METHODS: We retrospectively analyzed the hemodynamic data of 25 (n = 25) patients who underwent OLT during the last year (2008). All patients were monitored with a modified pulmonary artery catheter, which continuously measured the RVEF. Anesthetic technique consisted of either isoflurane or total intravenous anesthesia with propofol. Surgical technique was similar between groups. RESULTS: Ten (n = 10) patients comprised the isoflurane group (I), whereas 15 (n = 15) patients received propofol anesthesia (P). The RVEF was not significantly different between groups (I vs P, baseline: 41% ± 9% vs 40% ± 6%; anhepatic phase: 36% ± 8% vs 35% ± 6%; postreperfusion: 41% ± 6% vs 41% ± 8%; P = not significant). CONCLUSIONS: The choice between propofol and isoflurane seems to have minimal influence on the RVEF during OLT, which followed similar trends regardless of the anesthetic technique.

Perioperative coagulation profile in living liver donors as assessed by rotational thromboelastometry.

Transient postoperative coagulation abnormalities frequently occur in living liver donors, particularly after right liver resection. Usually, this coagulopathy is diagnosed by alterations in conventional coagulation tests (CCTs) such as the international normalized ratio (INR) of the prothrombin time. However, recent studies using other methods of coagulation monitoring have suggested that postoperative hypercoagulability may also occur in living donors. The rotational thromboelastometry (ROTEM) system is a coagulation monitor based on the viscoelastic properties of blood. The use of ROTEM for perioperative coagulation monitoring in the setting of living liver donors has not been reported. We evaluated the perioperative coagulation profile as assessed by ROTEM in 16 consecutive donors who underwent either right or left liver resection at our institution. ROTEM analysis and CCTs were performed at the baseline (before skin incision) and on postoperative days 1 and 3. According to the CCTs, hypocoagulability was revealed in all but 1 (left liver) donor. The INR was highest on postoperative day 1 [median = 1.67 (interquartile range = 1.37-1.8)]. In contrast, all donors had a normal coagulation profile as assessed by the ROTEM system throughout the study period. In conclusion, this study showed the disagreement between the CCTs and the ROTEM system, as no significant coagulation abnormalities could be revealed with the latter method during the study period. Further studies are needed to confirm the role of the ROTEM system as a perioperative coagulation monitor in this setting and ultimately its influence on the outcome of living donors.

Protamine sulphate for treatment of severe post-reperfusion coagulopathy in pediatric liver transplantation.

In this case report, we describe a child with biliary atresia who underwent a living LDLT and developed severe coagulopathy after reperfusion of the graft. The ROTEM analysis strongly suggested the presence of either a heparin effect or severe deficiency of coagulation factors. The former diagnosis was supported by a subsequent in-vitro HEPTEM. A small dose of protamine sulphate was then administered, which promptly restored hemostasis. The remainder of the procedure was uneventful.