Hemodynamics During Liver Transplantation

Use of Transesophageal Echocardiography for Liver Transplantation: A Global Comparison of Practice From the ILTS, SATA, and LICAGE

BACKGROUND

Anesthesiologists frequently use intraoperative transesophageal echocardiography (TEE) to aid in the diagnosis and management of hemodynamic problems during liver transplantation (LT). Although the use of TEE in US centers continues to increase, data regarding international use are lacking.

METHODS

This prospective, global, survey-based study evaluates international experience with TEE for LT. Responses from 252 LT (105 US and 147 non-US) centers representing 1789 anesthesiologists were analyzed.

RESULTS

Routine use of TEE in the United States has increased in the last 5 y (from 37% to 47%), but only 21% of non-US LT anesthesiologists use TEE routinely. Lack of training (44% US versus 70% non-US) and equipment (9% non-US versus 34% US) were cited as obstacles. Most survey participants preferred not to perform a complete cardiac examination but rather use only 6 of 11 basic views. Although non-US LT anesthesiologists more frequently had additional clinical training than their US counterparts, they had less TEE experience (13% versus 44%) and less frequently, TEE certification (22% versus 35%). Most LT anesthesiologists agreed that TEE certification is essential for proficiency. Of all respondents, 89% agreed or strongly agreed that TEE provides valuable information needed for immediate clinical decision-making, and >86% agreed or strongly agreed that that information could not be derived from other sources.

CONCLUSIONS

The use of TEE for LT surgery in the US LT centers is currently higher compared with non-US LT centers. This may become a standard monitoring modality during LT in the near future.

Hemodynamic monitoring in liver transplantation 'the hemodynamic system'

PURPOSE OF REVIEW

The purpose of this article is to provide a comprehensive review of hemodynamic monitoring in liver transplantation.

RECENT FINDINGS

Radial arterial blood pressure monitoring underestimates the aortic root arterial blood pressure and causes excessive vasopressor and worse outcomes. Brachial and femoral artery monitoring is well tolerated and should be considered in critically ill patients expected to be on high dose pressors. The pulmonary artery catheter is the gold standard of hemodynamic monitoring and is still widely used in liver transplantation; however, it is a highly invasive monitor with potential for serious complications and most of its data can be obtained by other less invasive monitors. Rescue transesophageal echocardiography relies on few simple views and should be available as a standby to manage sudden hemodynamic instability. Risk of esophageal bleeding from transesophageal echocardiography in liver transplantation is the same as in other patient populations. The arterial pulse waveform analysis based cardiac output devices are minimally invasive and have the advantage of real-time beat to beat monitoring of cardiac output. No hemodynamic monitor can improve clinical outcomes unless integrated into a goal-directed hemodynamic therapy. The hemodynamic monitoring technique should be tailored to the patient's medical status, surgical technique, and the anesthesiologist's level of expertise.

SUMMARY

The current article provides a review of the current hemodynamic monitoring systems and their integration in goal-directed hemodynamic therapy.

An overview of unresolved issues in the perioperative management of liver transplant patients

Over the past decade, the field of solid organ transplantation has undergone significant changes, with some of the most notable advancements occurring in liver transplantation. Recent years have seen substantial progress in preoperative patient optimization protocols, anesthesia monitoring, coagulation management, and fluid management, among other areas. These improvements have led to excellent perioperative outcomes for all surgical patients, including those undergoing liver transplantation. In the last few decades, there have been numerous publications in the field of liver transplantation, but controversies related to perioperative management of liver transplant recipients persist. In this review article, we address the unresolved issues surrounding the anesthetic management of patients scheduled for liver transplantation.

Liver Transplant Outcomes in Patients With Postcapillary Pulmonary Hypertension

Postcapillary pulmonary hypertension (PH) can be seen in cirrhosis. Research and treatment goals exist for patients with portopulmonary hypertension but not for postcapillary PH. The aim of this study was to investigate outcomes after liver transplant (LT) for patients with postcapillary PH.

Laparoscopic cytoreductive surgery and HIPEC is effective regarding peritoneum tissue paclitaxel distribution

BACKGROUND

In some patients with peritoneal carcinomatosis, we could perform the cytoreductive surgery and the HIPEC procedure by a complete laparoscopic approach to avoid morbidity. We consider that using laparoscopic approach for performing peritoneal carcinomatosis cytoreductive surgery and HIPEC with closed CO₂ recirculation technique is possible and safe, with equal efficacy to conventional methods and hemodynamic complications.

OBJECTIVE

Monitoring the effectiveness of the drug distribution in a laparoscopic ctoreductive and HIPEC surgery group with CO₂ recirculation respect to a closed and open HIPEC group METHODS: Porcine model that included fifteen mini-pigs. Five pigs were operated with laparoscopic approach performing a pelvic and retroperitoneal lymphadenectomy. They later received a total laparoscopic closed HIPEC with CO₂ recirculation (G1). Group 2 (G2): five pigs operated by an open cytoreductive surgery and closed HIPEC technique. Group 3 (G3): five animals in which an open cytoreductive surgery and an open HIPEC technique was performed. Blood and peritoneal determinations were realized after recirculation of the drug, at 60 min using chromatographic analysis.

RESULTS

G1-G2: phrenic right peritoneum, p: 0.46. Phrenic left peritoneum, p: 0.46. Pelvic peritoneum, p: 0.17. Serum paclitaxel: p: 0.01. G1-G3: phrenic right peritoneum, p: 0.34. Phrenic left peritoneum, p: 0.34. Pelvic peritoneum, p: 0.17. Serum paclitaxel G1-G3, p: 0.02.

CONCLUSIONS

A total laparoscopic approach for ctoreductive surgery and closed HIPEC with CO₂ recirculation may be safe and feasible. In our experimental model there was no significant difference in tissue drug distribution respect the conventional techniques and there was a less toxicity because the serum drug concentration was significantly lower with laparoscopic approach respect the other groups.

Transoesophageal echocardiography during orthotopic liver transplantation

Despite the importance of haemodynamic management in patients undergoing liver transplantation, there is currently no consensus on the most appropriate type of monitoring to use. In this context, transoesophageal echocardiography can provide useful information to professionals, although their use constraints prevent further spread today.

The Global End-Diastolic Volume (GEDV) Could Be More Appropiate to Fluid Management Than Central Venous Pressure (CVP) During Closed Hyperthermic Intrabdominal Chemotherapy with CO2 Circulation

BACKGROUND

Closed hyperthermic intraperitoneal chemotherapy (HIPEC) may increase abdominal pressure and effects of hemodynamic changes due to maintenance hyperthermia. Our aim was to analyze the safety and effectiveness of our closed technique with CO₂ circulation in management fluid status and hemodynamic parameters by means of cardiac preload control measured by Global End Diastolic Values (GEDV) and a gas exchanger.

MATERIAL AND METHODS

A Pilot Clinical Study that included 18 advanced ovarian cancer patients undergoing citoreductive surgery and HIPEC. We used a closed-perfusion system (PRS Combat®) that includes CO₂ circulation and a gas exchanger. Transpulmonary thermodilutions and hemodynamic measurements (PiCCO₂®) were performed after citoreductive surgery (Pre-HIPEC); At half time of the HIPEC (Intra-HIPEC); After HIPEC (Post-HIPEC).

RESULTS

No significant hemodynamic measurements changes in the three thermodilutions values of Cardiac Index (CI) (p = 0.227), Global End Diastolic Values (GEVD) (p = 0.966), Stroke Volume Variation (SVV) (p = 0,884) and Systemic Vascular Resistance Index (SVRI) (p = 0.082). No correlation between central venous pressure (CVP) and GEDV (Pre-HIPEC: r = 0.164, p = 0.211; Intra-HIPEC: r = 0.015, p = 0.900; Post-HIPEC: r = 0.018, p = 0.890). There was better correlation between GEDV and CI (Pre-HIPEC: r = 0.432, p = 0.071; Intra-HIPEC: r = 0.418, p = 0.074; Post-HIPEC: r = 0.411, p = 0.080).

CONCLUSIONS

Closed intrabdominal chemotherapy with CO₂ circulation model may be a safe model for HIPEC by means of a gas exchanger. GEDV and its changes significantly correlated to CI, and not observed for CVP. GEDV values may be more appropriate for monitoring cardiac preload, blood loss limitation and to predict changes in intravascular volume status during intraperitoneal chemotherapy.

Evaluation of cardiac output by bioreactance technique in patients undergoing liver transplantation

BACKGROUND

This study compared the cardiac output (CO) obtained from PiCCO with that obtained from the noninvasive NICOM method.

METHODS

Twenty-one cirrhotic patients receiving liver transplantation were enrolled. During the operation, their CO was measured by the PiCCO system via the thermodilution method as the standard and by the NICOM method. Two parameters including cardiac index (CI) and stroke volume index (SVI) were collected simultaneously at three phases during the surgery including the dissection phase (T1), the anhepatic phase (T2), and the reperfusion phase (T3). Correlation, Bland and Altman methods, and linear mixed model were used to evaluate the monitoring ability of both systems.

RESULTS

Poor correlation was noted between the data measured by NICOM and PiCCO; the correlation coefficients for CI and SVI measured between the two systems were 0.32 and 0.39, respectively. Bland and Altman analysis showed the percentage error of CI as 63.7%, and that of SVI as 66.6% for NICOM compared to PiCCO. Using the linear mixed model, the CI and SVI measured using NICOM were significantly higher than those using PiCCO (estimated regression coefficient 0.92 and 10.77, both p < 0.001). Mixed model analysis showed no differences between the trends of CI and SVI measured by the two methods.

CONCLUSIONS

NICOM provided a comparable CI and SVI trend when compared to the gold standard PiCCO, but it raises concerns as an effective CO monitor because of its tendency to overestimate CI and SVI especially during the state of high cardiac output.

Critical Care of the Liver Transplant Recipient

Patient survival following orthotopic liver transplantation has greatly increased following improvements in surgical technique, anesthetic care, and immunosuppression. The critical care of the liver transplant recipient has paralleled these improvements, largely thanks to input from multidisciplinary teams and institution-specific protocols guiding management and care. This article provides an overview of the approach to critical care of the postoperative adult liver transplant recipient outlining common issues faced by the intensivist. Approaches to extubation and hemodynamic assessment are described. The provision of appropriate immunosuppression, infection prophylaxis, and nutrition is addressed. To aid prompt diagnosis and treatment, intensivists must be aware of postoperative complications of bleeding, primary nonfunction, delayed graft function, vascular thromboses, biliary complications, rejection, and organ dysfunction.

Predicting fluid responsiveness with transthoracic echocardiography is not yet evidence based

An essential part of intensive care is to accurately identify fluid responders among patients with circulatory failure. Over the past few years, new techniques have been assessed for rapid and non-invasive prediction of fluid responsiveness. As transthoracic echocardiography (TTE) is becoming an integrated tool in the intensive care unit, this systematic review examined studies evaluating the predictive value of TTE for fluid responsiveness. In October 2012, we searched Pubmed, EMBASE and Web of Science for studies evaluating the predictive value of TTE-derived variables for fluid responsiveness defined as change in thermodilution cardiac output or stroke volume after a fluid challenge or a passive leg raising test. The use of thermodilution was used as inclusion criterion because it is the only method validated to show the change in cardiac output or stroke volume, which defines fluid responsiveness. Of the 4294 evaluated citations, only one study fully met our inclusion criteria. In this study, the predictive value of variations in inferior vena cava diameter (> 16%) for fluid responsiveness was moderate with sensitivity of 71% [95% confidence interval (CI) 44-90], specificity of 100% (95% CI 73-100) and an area under the receiver operating curve of 0.90 (95% CI 0.73-0.98). Only one study of TTE-based methods fulfilled the criteria for valid assessment of fluid responsiveness. Before recommending the use of TTE in predicting fluid responsiveness, proper evaluation including thermodilution technique as the gold standard is needed.

Perioperative monitoring in liver transplant patients

Liver transplant (LT) is a major surgical undertaking involving major fluid shifts, hemodynamic instability and metabolic derangements in a patient with preexisting liver failure and multisystemic derangements. Monitoring and organ support initiated in the preoperative phase is continued intraoperatively and into the postoperative phase to ensure an optimal outcome. As cardiovascular events are the leading cause of non-graft related death among LT recipients, major emphasis is placed on cardiovascular monitoring. The other essential monitoring are the continuous assessment of coagulapathy, extent of metabolic derangements, dyselectrolytemis and intracranial pressure monitoring in patients with fulminant hepatic failure. The type and extent of monitoring differs with need according to preexisting child status of the patient and the extent of systemic derangements. It also varies among transplant centers and is mainly determined by individual or institutional practices.

Optimizing cost-effectiveness in perioperative care for liver transplantation: a model for low- to medium-income countries

Although liver transplantation (LT) is a highly effective treatment, it has been considered too costly for publicly funded health systems in many countries with low to medium average incomes. However, with economic growth and improving results, some governments are reconsidering this position. Cost-effectiveness data for LT are limited, especially in perioperative care, and the techniques and costs vary widely between centers without overt differences in outcomes. Anesthesiologists working in new programs find it difficult to determine which modalities are essential, which are needed only in exceptional circumstances, and which may be omitted without effects on outcomes. We investigated key elements of preoperative evaluations, intraoperative management, and early postoperative care that might significantly affect costs in order to develop a best-value approach for new programs in resource-limited health systems. We identified all modalities of care commonly used in anesthesia and perioperative care for adult LT along with their costs. Those considered to be universally accepted as minimum requirements for safe care were excluded from the analysis, and so were those considered to be safe and low-cost, even when evidence of efficacy was lacking. The remaining items were, therefore, those with uncertain or context-restricted value and significant costs. A systematic review of the published evidence, practice surveys, and institutional guidelines was performed, and the evidence was graded and summarized. With respect to costs and benefits, each modality was then cited as strongly recommended, recommended or optional, or no recommendation was made because of insufficient evidence. Sixteen modalities, which included preoperative cardiovascular imaging, venovenous bypass, pulmonary artery catheterization, high-flow fluid warming devices, drug therapies for hemostasis, albumin, cell salvage, anesthetic drugs, personnel (staffing) requirements, and early extubation, were assessed. Only high-flow fluid warming was strongly recommended. The recommended modalities included preoperative echocardiography, cell salvage, tranexamic acid and early extubation. Six others were rated optional, and there was insufficient evidence for 5 modalities. We conclude that some costly techniques and treatments can be omitted without adverse effects on outcomes.

Dynamic left ventricular outflow tract obstruction in living donor liver transplantation recipients -A report of two cases-

We present two cases of dynamic left ventricular outflow tract obstruction in 2 patients who were undergoing living donor liver transplantation. On the preoperative transthoracic echocardiography, the first patient showed normal ventricular function and a normal wall thickness, but severe hemodynamic deterioration developed during the anhepatic period and this was further aggravated after reperfusion in spite of volume resuscitation and catecholamine therapy. Intraoperative transesophageal echocardiography revealed the systolic anterior motion of the mitral valve leaflet together with left ventricular outflow tract obstruction. The second patient showed left ventricular hypertrophy with left ventricular outflow tract obstruction on the preoperative echocardiography. Intraoperative transesophageal echocardiography was used to guide fluid administration and the hemodynamic management throughout the procedure and a temporary portocaval shunt was established to mitigate the venous pooling during the anhepatic period. The purpose of this report is to emphasize the clinical significance of dynamic left ventricular outflow tract obstruction in patients who are undergoing living donor liver transplantation and the role of intraoperative echocardiography to detect and manage it.

Perioperative considerations in patients with cirrhotic cardiomyopathy

PURPOSE OF REVIEW

This review aims to identify specific criteria for cirrhotic cardiomyopathy, examine the correlation with perioperative adverse outcomes and explore options for hemodynamic monitoring.

RECENT FINDINGS

Cirrhotic cardiomyopathy is characterized by an increase in cardiac output, blunted systolic contractile response to stress, diastolic dysfunction and electrophysiological abnormalities. Adverse events due to cirrhotic cardiomyopathy are not as well characterized, but evidence suggests that some cardiovascular complications during surgery and in the postoperative period are caused by an impaired response to physiological stress. New developments in hemodynamic monitoring using not only thermodilution technology provide more reliable information about cardiac performance than pressure-derived measures. Transesophogeal echocardiography also offers the physician new information including the ability to visualize heart structures, shape, and function.

SUMMARY

To detect cirrhotic cardiomyopathy, physicians must conduct a systematic examination of the patient. Overt manifestations of cirrhotic cardiomyopathy often only become evident after a patient is exposed to physiological or drug-induced stress. Appropriate hemodynamic monitoring is a cornerstone in the perioperative management of cirrhotic patients.

Intraoperative hemodynamic monitoring during organ transplantation: what is new?

PURPOSE OF REVIEW

To highlight the recent developments in hemodynamic monitoring during liver and lung transplantation.

RECENT FINDINGS

Even though a consensus on intraoperative hemodynamic monitoring is still lacking, the most frequently monitoring tool used is the pulmonary artery catheter (PAC). The filling pressures are widely accepted as not being able to accurately define cardiac preload. On the contrary, the use of transesophageal echocardiography (TEE), although it is operator dependent and requires a prolonged training, is increasing during the intraoperative period to directly evaluate the cardiovascular function. New frontiers have been opened by the transpulmonary thermodilution: intrathoracic blood volume has been shown to have a better correlation with preload than the filling pressures. The advanced modified PAC permits evaluation of the right heart function and preload. Recently, right ventricular end diastolic volume has been shown to correlate better with preload than the filling pressures and also the left ventricular end diastolic area.

SUMMARY

The PAC still represents the most used intraoperative hemodynamic monitoring technique. TEE is increasing in popularity. Recent studies demonstrate that volumetric monitoring conducted with transpulmonary thermodilution and advanced volumetric PAC give good definition of preload and should be implemented in clinical practice.

Current approach to intraoperative monitoring in liver transplantation

PURPOSE OF REVIEW

Although liver transplantation has become a standardized treatment and the only established definite therapy for end-stage liver disease it remains a unique clinical procedure. Increased understanding of the specific pathophysiological changes in end-stage liver disease and the transplantation procedure have led to the adaptation of concepts including overall monitoring of the patient and assessment of specific organ function.

RECENT FINDINGS

Major emphasis is placed on adequate monitoring during perioperative care of liver transplantation patients in order to ensure optimal hemodynamic and respiratory performance. The immediate assessment of metabolism and graft function will also serve to guide therapy according to the individual patient's needs.

SUMMARY

The evolution of monitoring during standardized liver transplantation, as well as currently recommended novel devices and concepts, are described and discussed.

Transesophageal echocardiography utilization in high-volume liver transplantation centers in the United States

OBJECTIVE

Transesophageal echocardiography (TEE) during liver transplantation (LT) has been shown to be helpful in managing fluid therapy, monitoring myocardial function, and identifying intraoperative LT complications. The present study sought to investigate the current utilization of TEE by anesthesiologists during LT as well as issues of training and credentialing in this monitoring modality.

DESIGN

A survey distributed by electronic mail.

SETTING

LT centers in the United States in which more than 50 liver transplantation procedures were performed annually.

PARTICIPANTS

Survey respondents were contact persons in the LT divisions of the anesthesiology department of selected centers.

INTERVENTIONS

Data collection only.

MEASUREMENT AND MAIN RESULTS

A total of 40 high-volume LT centers were identified, and survey responses were received from 30 of those. Among 217 anesthesiologists, 86% performed TEE in some or all LT cases. Most users performed a limited-scope examination, although some performed a comprehensive TEE examination during LT. Most users acquired their TEE skills informally. Only 12% of users were board certified to perform TEE, and only 1 center reported having a policy related to credentialing requirements for TEE.

CONCLUSIONS

There is high utilization of intraoperative TEE by anesthesiologists to perform limited-scope examinations during LT cases. Training to perform such examinations is mostly informal, and credentialing processes are lacking. An opportunity exists to establish guidelines, training programs, and standards for quality assurance in the use of this valuable monitoring modality.