Intraoperative circulatory management using the FloTrac™ system in laparoscopic liver resection

Prediction of postoperative complications after hepatectomy with dynamic monitoring of central venous oxygen saturation

BACKGROUND

The usefulness of static monitoring using central venous pressure has been reported for anesthetic management in hepatectomy. It is unclear whether intra-hepatectomy dynamic monitoring can predict the postoperative course. We aimed to investigate the association between intraoperative dynamic monitoring and post-hepatectomy complications. Furthermore, we propose a novel anesthetic management strategy to reduce postoperative complication.

METHODS

From 2018 to 2021, 93 patients underwent hepatectomy at our hospital. Fifty-three patients who underwent dynamic monitoring during hepatectomy were enrolled. Flo Trac system was used for dynamic monitoring. The baseline central venous oxygen saturation (ScvO2) was defined as the average ScvO2 for 30 min after anesthesia induction. ScvO2 fluctuation (ΔScvO2) was defined as the difference between the baseline and minimum ScvO2. Postoperative complications were evaluated using the comprehensive complication index (CCI).

RESULTS

Patients with ΔScvO2 ≥ 10% had significantly higher CCI scores (0 vs. 20.9: p = 0.043). In univariate analysis, patients with higher CCI scores demonstrated significantly higher preoperative C-reactive protein-to-lymphocyte ratio (7.51 vs. 24.49: p = 0.039), intraoperative bleeding (105 vs. 581 ml: p = 0.008), number of patients with major hepatectomy (4/45 vs. 3/8: p = 0.028), and number of patients with ΔScvO2 ≥ 10% (11/45 vs. 6/8; p = 0.010). Multivariate logistic regression analysis revealed that ΔScvO2 ≥ 10% (odds ratio: 9.53, p = 0.016) was the only independent predictor of elevated CCI.

CONCLUSIONS

Central venous oxygen saturation fluctuation during hepatectomy is a predictor of postoperative complications. Anesthetic management based on intraoperative dynamic monitoring and minimizing the change in ScvO2 is a potential strategy for decreasing the risk of post-hepatectomy complications.

Impact of conventional vs. goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver surgery: A pilot randomised controlled trial

BACKGROUND

Although fluid administration is a key strategy to optimise haemodynamic status and tissue perfusion, optimal fluid administration during liver surgery remains controversial.

OBJECTIVE

To test the hypothesis that a goal-directed fluid therapy (GDFT) strategy, when compared with a conventional fluid strategy, would better optimise systemic blood flow and lead to improved urethral tissue perfusion (a new variable to assess peripheral blood flow), without increasing blood loss.

DESIGN

Single-centre prospective randomised controlled superiority study.

SETTING

Erasme Hospital.

PATIENTS

Patients undergoing liver surgery.

INTERVENTION

Forty patients were randomised into two groups: all received a basal crystalloid infusion (maximum 2 ml kg-1 h-1). In the conventional fluid group, the goal was to maintain central venous pressure (CVP) as low as possible during the dissection phase by giving minimal additional fluid, while in the posttransection phase, anaesthetists were free to compensate for any presumed fluid deficit. In the GDFT group, patients received in addition to the basal infusion, multiple minifluid challenges of crystalloid to maintain stroke volume (SV) variation less than 13%. Noradrenaline infusion was titrated to keep mean arterial pressure more than 65 mmHg in all patients.

MAIN OUTCOME MEASURE

The mean intra-operative urethral perfusion index.

RESULTS

The mean urethral perfusion index was significantly higher in the GDFT group than in the conventional fluid group (8.70 [5.72 to 13.10] vs. 6.05 [4.95 to 8.75], P = 0.046). SV index (ml m-2) and cardiac index (l min-1 m-2) were higher in the GDFT group (48 ± 9 vs. 33 ± 7 and 3.5 ± 0.7 vs. 2.4 ± 0.4, respectively; P < 0.001). Although CVP was higher in the GDFT group (9.3 ± 2.5 vs. 6.5 ± 2.9 mmHg; P = 0.003), intra-operative blood loss was not significantly different in the two groups.

CONCLUSION

In patients undergoing liver surgery, a GDFT strategy resulted in a higher mean urethral perfusion index than did a conventional fluid strategy and did not increase blood loss despite higher CVP.

TRIAL REGISTRATION

NCT04092608.

Goal directed fluid therapy for major liver resection: A multicentre randomized controlled trial

Background

The effect a restrictive goal directed therapy (GDT) fluid protocol combined with an enhanced recovery after surgery (ERAS) programme on hospital stay for patients undergoing major liver resection is unknown.

Methods

We conducted a multicentre randomized controlled pilot trial evaluating whether a patient-specific, surgery-specific intraoperative restrictive fluid optimization algorithm would improve duration of hospital stay and reduce perioperative fluid related complications.

Results

Forty-eight participants were enrolled. The median (IQR) length of hospital stay was 7.0 days (7.0:8.0) days in the restrictive fluid optimization algorithm group (Restrict group) vs. 8.0 days (6.0:10.0) in the conventional care group (Conventional group) (Incidence rate ratio 0.85; 95% Confidence Interval 0.71:1.1; p = 0.17). No statistically significant difference in expected number of complications per patient between groups was identified (IRR 0.85; 95%CI: 0.45–1.60; p = 0.60). Patients in the Restrict group had lower intraoperative fluid balances: 808 mL (571:1565) vs. 1345 mL (900:1983) (p = 0.04) and received a lower volume of fluid per kg/hour intraoperatively: 4.3 mL/kg/hr (2.6:5.8) vs. 6.0 mL/kg/hr (4.2:7.6); p = 0.03. No significant differences in the proportion of patients who received vasoactive drugs intraoperatively (p = 0.56) was observed.

Conclusion

In high-volume hepatobiliary surgical units, the addition of a fluid restrictive intraoperative cardiac output-guided algorithm, combined with a standard ERAS protocol did not significantly reduce length of hospital stay or fluid related complications. Our findings are hypothesis-generating and a larger confirmatory study may be justified.

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Major liver resection is a complex procedure with up to 40% patients experiencing complications.

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Optimisation of perfusion and oxygen delivery to all organs remain the cornerstone of best hemodynamic care.

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Traditionally, a low central venous pressure strategy during major liver resection has been used to reduce venous bleeding.

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The impact of a restrictive cardiac output fluid optimisation algorithm during major liver surgery is unknown.

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After major hepatobiliary surgery, a fluid restrictive algorithm did not reduce length of hospital stay or complications.

A Comparative Study of Intraoperative Fluid Management Using Stroke Volume Variation in Liver Resection

Objective:

The aim of this study is to examine whether intraoperative fluid management with stroke volume variation (SVV) can achieve safe intravenous fluid restriction and contribute to decreasing intraoperative blood loss in liver surgery.

Background:

In liver surgery, maintaining the central venous pressure (CVP) at a low level is effective in decreasing intraoperative blood loss. Recently, several studies have suggested that SVV obtained using the FloTrac system demonstrated a better fluid responsiveness than CVP.

Methods:

We enrolled 30 patients undergoing liver resection since May 2015 in this prospective observational study, and we set the SVV target during liver transection at 13%–20% (SVV group). Forty-three cases of liver resection that we performed between January 2014 and March 2015 without using CVP or SVV were used as the Control group. We compared the 2 groups by using intraoperative blood loss as the primary endpoint.

Results:

There was no significant difference in patient characteristics between the 2 groups. The mean SVV during liver transection in the SVV group was 15.6 ± 4.4%. The infusion volume until completion of liver transection in the Control group was 9.4 mL/kg/h, whereas that of the SVV group was 3.3 mL/kg/h, a significantly lower volume (P &lt; 0.001). The median intraoperative blood loss was significantly decreased in the SVV group compared with the Control group (391 versus 1068 mL; P &lt; 0.001). The intraoperative transfusion rate was also significantly decreased in the SVV group.

Conclusion:

We demonstrated that intraoperative management with SVV can achieve safe intravenous fluid restriction and is useful for decrease intraoperative blood loss in liver surgery.

Fluid management in living donor hepatectomy: Recent issues and perspectives

The importance of the safety of healthy living liver donors is widely recognized during donor hepatectomy which is associated with blood loss, transfusion, and subsequent post-operative morbidity. Although the low central venous pressure (CVP) technique can still be effective, it may not be advantageous concerning the safety of healthy donors undergoing hepatectomy. Emerging evidence suggests that stroke volume variation (SVV), a simple and useful index for fluid responsiveness and preload status in various clinical situations, can be applied as a guide for fluid management to reduce blood loss during living donor hepatectomy. Synthetic colloid solutions are also associated with serious adverse events such as the use of renal replacement therapy and transfusion in critically ill or septic patients. However, it is uncertain whether the intra-operative use of colloid solution is associated with similarly adverse effects in patients undergoing living donor hepatectomy. In this review article we discuss the recent issues regarding the low CVP technique and the high SVV method, i.e., maintaining 10%-20% of SVV, for fluid management in order to reduce blood loss during living donor hepatectomy. In addition, we briefly discuss the effects of intra-operative colloid or crystalloid administration for surgical rather than septic or critically ill patients.