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Perioperative changes of intrathoracic blood volume index with ( ; ) or without (6) acute lung injury. No significant difference between groups. AH Z anhepatic phase; POD Z postoperative day; R1/2 Z 30 minutes after reperfusion; R2 Z 2 hours after reperfusion.
Source publication
Postoperative acute lung injury (ALI) after liver transplantation is clinically relevant and common. The perioperative thoracic fluid indices changes as well as the association with ALI in liver transplantation have not been thoroughly investigated.
Methods: A total of 52 consecutive adult recipients for elective living donor liver transplantation...
Context in source publication
Context 1
... ITBVI, CVP, and CI decreased significantly between the pretransplant phase and anhepatic phase [pretransplant ITBVI (802.9 AE 153.8 and 872.4 AE 137.9 mL/ m 2 ) vs. anhepatic ITBVI (695.5 AE 140.5 and 745.3 AE 139.2 mL/m 2 ) in both the injury and noninjury groups, respectively; time effect p < 0.001; Table 3, Figure 3; pretransplant CVP (7.6 AE 2.3 and 6.6 AE 1.6 mmHg) vs. anhepatic CVP (5.6 AE 2.4 and 4.3 AE 2.4 mmHg) in both the injury and noninjury groups, respectively; time effect p < 0.001; Table 3; pretransplant CI (4.6 AE 1.1 and 4.6 AE 1.1 L/min/m 2 ] vs. anhepatic CI (3.4 AE 1.0 and 3.5 AE 1.2 L/min/m 2 ) in both the injury and noninjury groups, respectively, time effect p < 0.001; Table 3]. After liver transplantation, ITBVI, CVP, and CI increased significantly above pretransplant levels beginning on POD1 in both groups (Table 3) and were comparable between groups at each time point. ...
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Objectives
In the presence of ischaemia/reperfusion (I/R) induced endothelial injury, volume administration may not correlate with increased microcirculation. The aim of this study was to evaluate intestinal microcirculation after standardised sequential volume loading in an animal model of I/R injury following supracoeliac aortic clamping.
Method...
Background
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Citations
... 3 Furthermore, higher pretransplant EVLW and PVPI levels have been associated with postoperative acute lung injury in living donor liver transplant patients. 4 Finally, TPTD may also be used to measure the cardiac index and global end diastolic volume, both of which may be used to guide fluid management in critically ill patients. 5 Therefore, use of TPTD in the perioperative period during liver transplantation has certain benefit. ...
Transpulmonary thermodilution is often used to measure extravascular lung water during liver transplantation. Here, the case of new onset atrial fibrillation during orthotopic liver transplantation, which may have been induced by iced saline injection for transpulmonary thermodilution measurement, is described. A 52-year-old male patient underwent orthotopic liver transplantation due to alcoholic cirrhosis combined with portal hypertension. During dissection of the recipient liver, transpulmonary thermodilution was performed. At 3 minutes following iced saline injected, atrial fibrillation occurred, the ventricular rate increased to more than 120 beats per min, and blood pressure dropped to 75/50 mmHg. Massive haemorrhage, inferior vena cava clamping, electrolyte disorder, acid-base balance disorder, and hypothermia were all ruled out, and iced saline injection was suspended. Hemodynamic stability was maintained with phenylephrine and lanatocide C (cedilanid), and chemical cardioversion was performed using amiodarone. During the reperfusion phase, transient hemodynamic instability was managed by norepinephrine. The neohepatic phase was uneventful. Atrial fibrillation lasted for 5 days and reversed to sinus rhythm automatically. The patient was hemodynamically stable during this period, and recovery was smooth with no thromboembolic events. In conclusion, atrial fibrillation may be induced by iced saline injection for transpulmonary thermodilution measurement during orthotopic liver transplantation.
... continuedOne exposure-based cohort study (restrictive vs liberal fluid management) did not show any difference 67 (eTable 3b). Six studies used pulmonary complications as an outcome to categorize the cohort.[58][59][60][61][62][63] Two studies did not show any difference in the volume received between the groups59,63 and four reported a higher mean (SD) intraoperative crystalloid volume in the pulmonary complications group [1509 (907) vs 1088 (572) mL; P = 0.03] 58 ; total fluid[100 mLÁkg -1 in 81% of patients vs 58%; P = 0.014; 60 total fluid[10 L in 77% of patients vs 52%; P = 0.008, 61 and median total fluid of 12.8 L vs 8.3-10.3 ...
... Six studies used pulmonary complications as an outcome to categorize the cohort.[58][59][60][61][62][63] Two studies did not show any difference in the volume received between the groups59,63 and four reported a higher mean (SD) intraoperative crystalloid volume in the pulmonary complications group [1509 (907) vs 1088 (572) mL; P = 0.03] 58 ; total fluid[100 mLÁkg -1 in 81% of patients vs 58%; P = 0.014; 60 total fluid[10 L in 77% of patients vs 52%; P = 0.008, 61 and median total fluid of 12.8 L vs 8.3-10.3 L in a ''late'' pulmonary edema group vs other groups; P\0.05 62 (eTable 2c). ...
Purpose
Restrictive fluid management strategies have been proposed to reduce complications in liver transplant recipients. We conducted a systematic review to evaluate the effects of restrictive perioperative fluid management strategies, compared with liberal ones, on postoperative outcomes in adult liver transplant recipients. Our primary outcome was acute kidney injury (AKI). Our secondary outcomes were bleeding, mortality, and other postoperative complications.
Source
We searched major databases (CINAHL, EMB Reviews, EMBASE, MEDLINE, and the grey literature) from their inception to 10 July 2018 for randomized-controlled trials (RCTs) and observational studies comparing two fluid management strategies (or observational studies reporting two outcomes with available data on fluid volume received) in adult liver transplant recipients. Study selection, data abstraction, and risk of bias assessment were performed by at least two investigators. Data from RCTs were pooled using risk ratios (RR) and mean differences (MD) with random-effect models.
Principal findings
We found seven RCTs and 29 observational studies. Based on RCTs, fluid management strategies did not have any effect on AKI, mortality, or any other postoperative complications. Intraoperative RCTs suggested that a restrictive fluid management strategy reduced pulmonary complications (RR, 0.69; 95% confidence interval [CI], 0.47 to 0.99; n = 283; I² = 27%), duration of mechanical ventilation (MD, -13.04 hr; 95% CI, -22.2 to -3.88; n = 130; I² = 0%) and blood loss (MD, -1.14 L; 95% CI, -1.72 to -0.57; n = 151; I² = 0%).
Conclusion
Based on low or very low levels of evidence, we did not find any association between restrictive fluid management strategies and AKI, but we observed possible protective effects of intraoperative restrictive fluid management strategies on other outcomes.
Trial registration
PROSPERO (CRD42017054970); registered 18 May, 2017.
... Perioperative Management. We followed the methods of Chan et al. 2017 [20]. General anesthesia was regulated by maintaining the bispectral index between 40 and 60 during surgery. ...
Background:
Acute respiratory distress syndrome (ARDS) after living-donor liver transplantation (LDLT) is not uncommon, but it lacks the biomarkers for early detection. Club cell protein 16 (CC16), high-motility group box 1 protein (HMGB1), interleukin-1β (IL-1β), and IL-10 have been reported as relevant to the development of ARDS. However, they have not been investigated during LDLT.
Methods:
Seventy-three consecutive recipients undergoing LDLT were enrolled and received the same perioperative care plan. Perioperative serum CC16, HMGB1, IL-1β, and IL-10 levels were measured at the pretransplant state, 30 minutes after reperfusion, postoperative day 1 (POD1), and POD3. ARDS was diagnosed according to the 2012 Berlin definition.
Results:
Of the 73 recipients, 13 developed ARDS with significantly longer durations of mechanical ventilation and intensive care unit stay. Serum CC16 levels on POD1 increased significantly from the pretransplant state in the ARDS group but not in the non-ARDS group. Pretransplant serum CC16 levels were also higher in the ARDS group. The area under the receiver operating characteristic curves for POD1 serum CC16 levels used to discriminate ARDS was 0.803 (95% confidence interval: 0.679 to 0.895; p < 0.001). By comparison, HMGB1, IL-1β, and IL-10 were not associated with ARDS after LDLT.
Conclusion:
The higher pretransplant serum CC16 level and its increased level on POD1 were associated with the development of early ARDS after LDLT. This trial is registered with NCT01936545, 27 August 2013.
Background
Liver transplantation is associated with significant blood loss, often requiring massive blood product transfusion. Transfusion-related acute lung injury (TRALI) is a devastating cause of transfusion-related deaths. While reports have investigated the general incidence of TRALI, the incidence of TRALI specifically following transfusion during liver transplant remains unclear. This scoping review summarizes existing literature regarding TRALI during the liver transplantation perioperative period.
Methods
Databases were searched for all articles and abstracts reporting on TRALI after liver transplantation. Data collected included: number of patients studied; patient characteristics; incidences of TRALI; TRALI characteristics; and patient outcomes. The primary outcome investigated was the incidence of TRALI in the setting of liver transplantation.
Results
13 full-text citations were included in this review. The incidence of TRALI post-liver transplant was 0.68% (65/9554). Based on reported transfusion data, patients diagnosed with TRALI received an average of 10.92 ± 10.81 units of pRBC, 20.05 ± 15.72 units of FFP, and 5.75 ± 10.00 units of platelets. Common interventions following TRALI diagnosis included mechanical ventilation with positive end-expiratory pressure (PEEP), inhaled high-flow oxygen, inhaled pulmonary vasodilator, and pharmacological treatment using pressors or inotropes, corticosteroids, or diuretics. Based on reported mortality data, 26.67% of patients (12 out of 45) diagnosed with TRALI died during the postoperative period.
Conclusions
This scoping review underscores the importance of better understanding the incidence and presentation of TRALI after liver transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for liver transplant patients at increased risk for developing TRALI.
End-stage liver disease or cirrhotic patients frequently require admission to an intensive care unit for the treatment of organ failure. Mechanical ventilation, which is frequently required, is consistently associated with a significantly increased rate of in-hospital mortality. Despite a lack of research focused on the cirrhotic population, there is a growing body of evidence from the general ICU or perioperative population showing that appropriate management of ventilatory support is associated with improved outcomes. Moreover, synergistic ventilatory strategies from the preoperative ICU period to the intraoperative and then the postoperative period may be an important pathway for further improvements in the outcomes of these patients.
