Association between central venous pressure and blood loss during hepatic resection in 984 living donors

Background: Although low central venous pressure (CVP) anesthesia has been used to minimize blood loss during hepatectomy, the efficacy of this technique remains controversial. We therefore assessed the association between blood loss and CVP during hepatic resection, and examined significant determinants associated with intraoperative hemorrhage during hepatectomy in living donors.
Methods: Between April 2004 and April 2008, 984 living donors who underwent a hepatic resection were assessed retrospectively. Univariate and multivariate analyses were performed to explore the relationships between intraoperative blood loss and several variables including CVP.
Results: The mean intraoperative blood loss was 691.3 ± 365.5 ml. Only four donors required packed red blood cell transfusions (mean, 1.5 U). The mean duration of hepatic resection was 92.1 ± 26.3 min. The mean, maximum, and minimum values of CVP measured during hepatectomy were 4.6 ± 1.7, 5.3 ± 1.8, and 4.0 ± 1.8 mmHg, respectively, and were not significantly correlated with intraoperative blood loss. On multivariate analysis, predictors of hemorrhage were liver fatty change, gender, and body weight, but none of the mean CVP, surgeons, anesthesiologists, anesthesia duration, resected liver volume, hepatectomy type, systolic blood pressure, heart rate, or body temperature were significant.
Conclusions: CVP during hepatic resection was not associated with intraoperative blood loss in living liver donors, suggesting that CVP may not be an important factor in predicting blood loss during hepatectomy in healthy subjects.     

急性高容量血液稀释联合低中心静脉压在肝叶切除术中的应用

目的探讨肝叶切除术中应用急性高容量血液稀释(AHHD)联合低中心静脉压(LCVP)减少出血量的临床效果。方法肝叶切除术患者60例,ASAⅠ或Ⅱ级,随机均分为三组,分别对患者实施LCVP(A组)、AHHD(B组)及LCVP联合AHHD(C组),并连续监测SBP、DBP、MAP、CVP。术中采集中心静脉血及桡动脉血测定Hb,并检查三组术中出血量。结果与麻醉诱导后比较,肝实质阻断前后及手术结束时三组Hb均明显降低(P<0.01)。B组肝实质横断时出血量及总出血量明显高于A、C组(P<0.01)。结论 LCVP联合AHHD应用于肝叶切除术中能够减少术中出血量,且对氧供需平衡无影响。     

Anesthesia in the patient with impaired liver function

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.     

控制性低中心静脉压在原发性肝癌伴肝炎后肝硬化患者腹腔镜肝切除中的应用

背景与目的:在肝脏切除手术中采用控制性低中心静脉压(CLCVP)技术可有效减少肝断面出血,然而,低中心静脉压(CVP)所产生的相对低血压和潜在低灌注可能造成不良影响,这使其推广应用受到一定程度的限制。本研究探讨CLCVP技术在原发性肝癌伴肝炎后肝硬化患者腹腔镜肝切除手术中的应用效果和安全性。方法:回顾性分析2017年4月—2019年3月在安徽医科大学第一附属医院肝胆胰外科行全腹腔镜解剖性肝切除手术的44例原发性肝癌伴肝炎后肝硬化患者临床资料,所有患者均接受同一组医生手术,其中24例患者术中采用CLCVP技术(观察组),另外20例患者术中未采用CLCVP对照组(对照组),分析并比较两组术前、术中、术后的相关临床资料。结果:两组患者术前资料包括性别、年龄、BMI、Child分级、肝硬化程度、肝肾功能指标差异均无统计学意义(均P0.05)。两组手术均顺利完成,无围手术期死亡病例。观察组术中、术后均未见低CVP相关气栓、肝肾损伤等并发症。与对照组比较,观察组术中动脉收缩压、CVP明显降低,手术时间与肝门阻断时间明显缩短、术中出血和手术输血率明显降低,但术中乳酸指标明显升高(均P0.05)。两组的术后出血、感染、胸腔积液、胆汁漏的发生率以及肝肾功能指标、拔管时间、住院时间方面均无统计学差异(均P0.05),但观察组患者术后引流量多于对照组(P0.05);两组术后复发率亦无统计学差异(P0.05)。结论:在做好术前肝功能评估和术中密切观测患者灌注指标的前提下,CLCVP技术对肝炎后肝硬化患者腹腔镜肝切除手术是安全可靠的,虽然低CVP会使机体灌注减少,机体无氧代谢增强,乳酸含量增高,但对肝肾功能及肝癌的复发无明显影响,而且较低的CVP能够有效减少术中出血量和输血量,缩短手术时长和肝门阻断时间,降低长时间缺血缺氧对肝脏的打击。总之,在无严重心、肺、脑、肾基础疾病的肝炎后肝硬化患者腹腔镜肝切除手术中,CLCVP是一种值得推荐的控制肝断面出血技术。     

低中心静脉压联合Habib 4X应用对肝叶切除术中出血量的影响

目的观察控制性低中心静脉压技术联合Habib4X射频止血切割器应用对肝叶切除术中出血量的影响。方法择期全麻下因肝血管瘤需行肝叶切除手术的患者80例,ASAⅠ或Ⅱ级,随机均分为控制性低中心静脉压联合Habib4X组(L组)和正常中心静脉压联合传统缝扎法组(C组)。L组在肝实质完全离断过程中将CVP控制在0～5cm H2O,C组维持CVP在6～12cm H2O。观察两组患者术中总出血量、输血量、输血例数、肝门阻断例数、肝实质离断时间和肝实质离断后及术后24h肾功能变化。结果 L组手术总出血量、输血量、输血率、肝门阻断率、肝实质离断时间明显低于C组(P<0.05)。两组患者尿量差异无统计学意义,肝实质离断后、术后24h肾功能无明显变化。结论控制性低中心静脉压技术联合Habib4X射频止血切割器应用可减少肝叶切除术出血量和输血量。     

选择性肝左、右动脉阻断联合控制性低中心静脉压在肝叶切除手术的应用临床研究

目的观察选择性肝左、右动脉阻断联合控制性低中心静脉压术中出血量的影响。方法择期全麻下行肝叶切除术患者24例。分为两组：低中心静脉压组（LCVP组）和选择性肝左、右动脉阻断联合控制性低中心静脉压组（S组）。二组患者均为12例。两组患者在肝实质完全离断过程中CVP控制在0～0．49kPa水平。测量两组患者术中出血量。结果选择性肝左、右动脉阻断联合控制性低中心静脉压组和LCVP组术中出血量分别为（313±167）ml和（474±222）ml（P〈0．05）。结论选择性肝左、右动脉阻断联合控制性低中心静脉压较单存低中心静脉压可减少肝叶切除手术术中出血量。     

肝下下腔静脉阻断与控制性低中心静脉压在复杂肝切除术中应用的比较

目的:比较肝下下腔静脉(IIVC)阻断与控制性低中心静脉压(CLCVP)技术在复杂肝切除术中应用的安全性及有效性。方法:回顾性分析2016年3月—2017年12月行复杂肝切除术的103例原发性肝癌患者临床资料,术中所有患者均采用Pringle法控制入肝血流,其中56例行IIVC阻断(IIVC阻断组),47例行CLCVP技术(CLCVP组)降低中心静脉压(CVP)。比较两组切肝过程中CVP的变化、切肝过程出血量、手术总出血量、术中尿量、输血率、术后并发症发生率、术后肝功能与肾功能变化。结果:两组患者一般资料差异无统计学意义(均P0.05)。与切肝前对比,两组患者在切肝过程中CVP均明显下降,但IIVC阻断组CVP较CLCVP降低更明显,且IIVC阻断组切肝过程中出血量、手术总出血量、术后第3天ALT和术后第3、7天TBIL均明显低于CLCVP组(均P0.05)。两组患者术中尿量、输血率及术后并发症发生率、肾功能情况差异无统计学意义(均P0.05)。结论:IIVC阻断联合Pringle法操作简单方便,相对于CLCVP技术,其对全身血流动力学影响较小,肝功能恢复更快,且更容易降低CVP,减少术中肝脏断面出血,有利于提高复杂肝切除术的安全性。     

Anesthetic Techniques and Surgical Blood Loss in Total Hip Arthroplasty

Blood loss during total hip arthroplasty and the relation of different anesthetic techniques to surgical bleeding was explored in a consecutive, prospective study involving 157 patients with no previous history of hip surgery. Intraoperative blood loss was significantly reduced in patients operated under sodium nitroprusside induced hypotensive anesthesia as compared to halothane, NLA or epidural block. It might be suspected that postoperative blood loss is increased when the lowered blood pressure is raised towards normotension, but this was not the case. However, regression analysis between mean arterial pressure and intraoperative blood loss in patients anesthetized with hypotensive as well as “normotensive” techniques showed a poor correlation. Blood loss was greater with NLA and halothane anesthesia than with epidural block. The authors consider controlled hypotension a useful adjuvant in anesthesia for total hip arthroplasty in selected patients. Epidural block, on the other hand, is a suitable anesthetic technique for most patients and has the additional advantage of reduced surgical bleeding as compared to general anesthesia.     

肝叶切除术患者低中心静脉压联合急性高容量血液稀释的血液保护效应

目的 评价肝叶切除术患者低中心静脉压(CVP)联合急性高容量血液稀释(AHHD)的血液保护效应.方法 择期行肝叶切除术的肝癌患者60例,随机分为3组(n=20):对照组(Ⅰ组)、AHHD组(Ⅱ组)和低CVP联合AHHD组(Ⅲ组),3组均采用硬膜外复合全麻.Ⅰ组术中按1.5∶1输注晶体液和胶体液;Ⅱ组在气管插管后静脉输注4%琥珀酰明胶50 ml·kg-1.h-130min行AHHD,然后静脉输注乳酸钠林格氏液维持CVP在正常范围;Ⅲ组入室后静脉输注乳酸钠林格氏液1 ml·kg-1·h-1,硬膜外输注1.5%利多卡因和0.2%布比卡因混合液6～8 ml,静脉输注异丙酚6 mg·kg-1·h-1,维持CVP 1～5 cm H2O,同时静脉输注去甲肾上腺素0.4～0.8 mg/h,维持MAP≥70 mm Hg,肝叶切除后10min开始行AHHD.分别于术前(基础状态)、切皮前即刻、肝叶切除前即刻、肝叶切除后10 min和术毕时测定血糖浓度,分别于上述时点及术后7 d测定血红蛋白(Hb)、红细胞压积(Hct)、白细胞(WBC)、凝血功能指标、谷丙转氨酶(GPT)和肾功能指标,并记录各时段输液量、尿量;记录术中失血、输血情况及术后并发症的发生情况.结果 与Ⅰ组和Ⅱ组比较,Ⅲ组术中血糖、WBC、GPT、失血量、异体输血量、肝叶切除前输液量、尿量及异体输血率较低,术中Hb、Hct及肝叶切除后输液量和尿量较高(P＜0.05),凝血功能指标、肾功能指标、总输液量和尿量差异无统计学意义(P＞0.05).所有患者术后未见并发症发生.结论 肝叶切除前低CVP联合肝叶切除后AHHD能明显减少术中失血量和异体输血,且具有良好的安全性.     

Low Central Venous Pressure with Milrinone During Living Donor Hepatectomy

Maintaining a low central venous pressure (CVP) has been frequently used in liver resections to reduce blood loss. However, decreased preload carries potential risks such as hemodynamic instability. We hypothesized that a low CVP with milrinone would provide a better surgical environment and hemodynamic stability during living donor hepatectomy. Thirty‐eight healthy adult liver donors were randomized to receive either milrinone (milrinone group, n = 19) or normal saline (control group, n = 19) infusion during liver resection. The surgical field was assessed using a four‐point scale. Intraoperative vital signs, blood loss, the use of vasopressors and diuretics and postoperative laboratory data were compared between groups. The milrinone group showed a superior surgical field (p < 0.001) and less blood loss (142 ± 129 mL vs. 378 ± 167 mL, p < 0.001). Vital signs were well maintained in both groups but the milrinone group required smaller amounts of vasopressors and less‐frequent diuretics to maintain a low CVP. The milrinone group also showed a more rapid recovery pattern after surgery. Milrinone‐induced low CVP improves the surgical field with less blood loss during living donor hepatectomy and also has favorable effects on intraoperative hemodynamics and postoperative recovery.     

Central venous pressure monitoring during living right donor hepatectomy.

Low central venous pressure (CVP) has been advocated during liver resection to reduce blood loss and transfusion requirements. As a consequence, CVP catheter placement has been considered essential for hepatic surgery, including living donor hepatectomies. We retrospectively analyzed whether intraoperative management without CVP monitoring influenced fluid administration, blood loss, and patient outcome. Medical charts and hospital data system of 50 adult to adult living liver donors were retrospectively reviewed. Data collection included patient demographics, intraoperative variables such as fluid management, blood loss, urine output, and operating room time. Postoperative variables were collected during the postanesthesia care unit stay and for the first 24 hours after surgery. Patients were then grouped on the basis of the presence or absence of a CVP catheter. Data were reanalyzed and groups compared. Patient groups did not differ in terms of demographics at baseline. When divided into groups with CVP and without CVP, the presence of CVP did not result in decreased intraoperative fluid administration. All patients were hemodynamically stable, and renal function was not different between groups throughout hospitalization. Length of postanesthesia care unit and hospital stay was the same. There was no difference in the frequency of complications during the hospital stay and at 3 months' follow-up. CVP monitoring did not appear to reduce blood loss when compared with patients without CVP monitoring. In centers with extensive experience, CVP monitoring may not be necessary in this highly selective patient population.     

The introduction of a simple maneuver to reduce the risk of postoperative bleeding after major hepatectomies

Background/Purpose  In major hepatectomies, postoperative increases in central venous pressure (CVP) may cause suture failure and massive bleeding. The aim of our study is to test the application of an intraoperative maneuver to reduce the risk of postoperative bleeding. Methods  Our study included 172 consecutive patients who had major liver resection with selective hepatic vascular exclusion and sharp transection of the liver parenchyma. An intraoperative maneuver (5 s occlusion of the hepatic vein) was applied in an alternating way, and the patients were assigned to two groups: Cohort A (n = 86), that was granted the maneuver, and Cohort B (n = 86), that was used as a control group. Results  In Cohort A, application of the maneuver was successful in demonstrating bleeders under low CVP levels. Cohort A had lower rate of massive bleeding requiring emergency reoperation (2.3 vs 5.8%, P = 0.049), less postoperative blood transfusions (13 vs 24%, P = 0.042), lower morbidity (20 vs 35%, P < 0.045) and shorter hospital stay compared to Cohort B. Conclusions  Hepatectomies conducted under low CVP are prone to postoperative hemorrhage which can be prevented if the final bleeding control is performed under high pressure in the hepatic veins. Application of our testing maneuver effectively unmasked previously undetectable bleeding veins.     

Co-existing liver disease increases the risk of postoperative thrombocytopenia in patients undergoing hepatic resection: implications for the risk of epidural hematoma associated with the removal of an epidural catheter

Purpose

A common surgical diagnosis for hepatic resection in Japan is hepatocellular carcinoma secondary to chronic viral hepatitis. It is known that chronic liver disease causes a decrease in blood platelet count. We retrospectively reviewed the perioperative changes in blood platelet count associated with hepatic resection at a Japanese institution and evaluated the incidence and risk factors for postoperative thrombocytopenia, which may increase the potential risk of epidural hematoma.

Methods

We analyzed the data of 165 patients who underwent hepatic resection between 1 March 2010 and 30 June 2012 at Hokkaido University Hospital. The criterion of the platelet count for the unsafe removal of epidural catheter was <100,000/μL. Logistic regression was used to model the association between postoperative thrombocytopenia and co-existing liver disease, estimated blood loss and type of hepatic resection.

Results

After hepatic resection, 42.4 % of patients without preoperative thrombocytopenia experienced thrombocytopenia. The presence of co-existing liver disease was identified as a risk factor for postoperative thrombocytopenia [odds ratio 3.17 (95 % confidence interval 1.63–6.18)]. There was no epidural hematoma in the 149 patients who had epidural anesthesia.

Conclusion

Hepatic resection can cause postoperative thrombocytopenia that may increase the potential risk of epidural hematoma associated with catheter removal, and the presence of co-existing liver disease heightens concerns for postoperative crucial thrombocytopenia.     

The Effect of Anesthesia on Intraoperative and Postoperative Bleeding during Abdominal Prostatectomies: A Comparison of Neurolept Anesthesia, Halothane Anesthesia and Epidural Anesthesia

Intraoperative blood loss was measured during abdominal prostatectomies in 213 patients anesthetized with neurolept anesthesia, halothane anesthesia and epidural anesthesia. In 55 of these patients, postoperative bleeding was also measured. The average intraoperative blood loss with neurolept anesthesia was 8.2 ± 5 ml/min, with halothane anesthesia 6.6 ± 6.3 ml/min and with epidural anesthesia 3.8 ± 2.3 ml/min. The difference of blood loss in the epidural group and in the groups receiving general anesthesia is highly significant.
Average systolic and diastolic blood pressures were lower during operation in the epidural group than in the other two groups. Statistical analyses failed, however, to show a significant correlation between blood pressures and blood loss in the individual patient. Thus, the ultimate explanation for the diminished bleeding associated with epidural anesthesia is not definitely ascertained. The average postoperative bleeding was not significantly different among the three anesthetic groups.     

Intraoperative fluid management during orthotopic liver transplantation

OBJECTIVE: To assess clinical safety of a low central venous pressure (CVP) fluid management strategy in patients undergoing liver transplantation. DESIGN: Retrospective record review comparing 2 transplant centers, one using the low CVP method and the other using the normal CVP method. SETTING: University-based, academic, tertiary care centers. PARTICIPANTS: Patients undergoing orthotopic cadaveric liver transplantation. INTERVENTIONS: Each center practiced according to its own standard of care. Center 1 maintained an intraoperative CVP <5 mmHg using fluid restriction, nitroglycerin, forced diuresis, and morphine. If pressors were required to maintain systolic arterial pressure >90 mmHg, phenylephrine or norepinephrine was used. At center 2, CVP was kept 7 to 10 mmHg and mean arterial pressure >75 mmHg with minimal use of vasoactive drugs. MEASUREMENTS and MAIN RESULTS: Data collected included United Network for Organ Sharing status, surgical technique, intraoperative transfusion rate, preoperative and peak postoperative creatinine, time spent in intensive care unit and hospital, incidence of death, and postoperative need for hemodialysis. Principal findings include an increased rate of transfusion in the normal CVP group but increased rates of postoperative renal failure (elevated creatinine and more frequent need for dialysis) and 30-day mortality in the low CVP group. CONCLUSIONS: Despite success in lowering blood transfusion requirements in liver resection patients, a low CVP should be avoided in patients undergoing liver transplantation.     

控制性低中心静脉压联合肝蒂阻断在肝切除术中的应用

目的 探讨控制性低中心静脉压联合肝蒂阻断技术对肝切除术中出血量及术后肝肾功能的影响。方法 将2011年3月至2012年9月我院行肝切除术的患者106例,随机分为控制性低中心静脉压组（CLCVP组,53例）和正常中心静脉压组（NCVP组,53例）。CLCVP组切肝时通过控制输液量和药物使CVP维持在0～5 cm H2O,维持动脉收缩压≥90 mm Hg,NCVP组维持CVP在6～12 cm H2O。观察两组患者术中出血量及术后肝肾功能的变化。结果 CLCVP组术中出血量和输血量低于NCVP组[（236.5±128.2）mL vs（415.8±383.6）mL,（368.5±269.8）mL vs（206.8±131.4 mL）],差异有统计学意义（P＜0.05）;两组术后肝肾功能变化差异无统计学意义（P＞0.05）。结论 在肝切除术中,控制性低中心静脉压联合肝蒂阻断技术能有效地减少术中出血量和输血量,且对患者肝肾功能无明显影响。     

Laparoscopic radiofrequency–assisted liver resection

Laparoscopic liver resection has not yet gained wide acceptance among hepatic surgeons, mainly because of the difficulties encountered in dealing with possible intraoperative bleeding. A new technique of laparoscopic liver resection is presented. A 43-year-old man with a large and symptomatic hemangioma underwent a laparoscopic radiofrequency energy–assisted liver resection. After induction of pneumoperitoneum, four trocars were introduced and intraoperative ultrasonography and coagulative desiccation were performed along a plane of tissue 1 cm away from the edge of the lesion using the Cool-Tip radiofrequency probe and a 500-kHz, radiofrequency generator. The necrosed band of parenchyma then was divided and the specimen removed. The operative time was 300 min with a resection time of 240 min. The intraoperative blood loss was 75 ml. The postoperative course was uneventful and the patient was discharged on postoperative day 6. Laparoscopic radiofrequency–assisted liver resection is feasible, and with greater experience may contribute to the wider use of mini-invasive video-assisted liver surgery.     

Laparoscopic radiofrequency-assisted liver resection

Laparoscopic liver resection has not yet gained wide acceptance among hepatic surgeons, mainly because of the difficulties encountered in dealing with possible intraoperative bleeding. A new technique of laparoscopic liver resection is presented. A 43-year-old man with a large and symptomatic hemangioma underwent a laparoscopic radiofrequency energy-assisted liver resection. After induction of pneumoperitoneum, four trocars were introduced and intraoperative ultrasonography and coagulative desiccation were performed along a plane of tissue 1 cm away from the edge of the lesion using the Cool-Tip radiofrequency probe and a 500-kHz, radiofrequency generator. The necrosed band of parenchyma then was divided and the specimen removed. The operative time was 300 min with a resection time of 240 min. The intraoperative blood loss was 75 ml. The postoperative course was uneventful and the patient was discharged on postoperative day 6. Laparoscopic radiofrequency-assisted liver resection is feasible, and with greater experience may contribute to the wider use of mini-invasive video-assisted liver surgery.     

Intraoperative blood salvage during liver resection: a randomized controlled trial

OBJECTIVE: A randomized controlled trial was conducted to clarify the effectiveness of intraoperative blood salvage in reducing blood loss. BACKGROUND: Although reduction of central venous pressure (CVP) is thought to decrease blood loss during liver resection, no consistently effective and safe method for obtaining the desired reduction of CVP has been established. METHODS: Living liver donors scheduled to undergo liver graft procurement were randomly assigned to a blood salvage group, in which a blood volume equal to approximately 0.7% of the patient's body weight was collected before the liver transection, or a control group. The surgeons were blinded to the randomization results. The primary outcome measure was blood loss during liver parenchymal division. A multivariate analysis was also performed. RESULTS: Seventy-nine donors were allocated intraoperatively to the blood salvage group (n = 40) or the control group (n = 39). The amount of blood loss during liver transection was significantly smaller in the blood salvage group than in the control group (median loss during transection, 140 mL vs. 230 mL, P = 0.034). The CVP at the beginning of the liver parenchymal division was significantly lower in the blood salvage group than in the control group (median, 5 cm H2O vs. 6 cm H2O, P = 0.005). The results of a multivariate analysis revealed that intraoperative blood salvage offered the advantage of reduced blood loss during liver parenchymal division (adjusted OR, 0.31; 95% CI, 0.11-0.85, P = 0.025). CONCLUSION: Modest intraoperative blood salvage significantly and safely reduced blood loss during hepatic parenchymal transection.