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Pianngarn I, Lapisatepun W, Kulpanun M, Chotirosniramit A, Junrungsee S, Lapisatepun W. The effectiveness and outcomes of epidural analgesia in patients undergoing open liver resection: a propensity score matching analysis. BMC Anesthesiol 2024; 24:305. [PMID: 39223470 PMCID: PMC11367829 DOI: 10.1186/s12871-024-02697-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection. METHODS A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects. RESULTS A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). CONCLUSIONS Epidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance. TRIAL REGISTRATION The study was registered in the Clinical Trials Registry at www. CLINICALTRIALS gov/ , NCT number: NCT06301932.
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Affiliation(s)
- Isarapong Pianngarn
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
| | - Worakitti Lapisatepun
- Department of Surgery, Division of Hepatobilliary Pancreatic Surgery, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
- Clinical Surgical Research Center, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
| | - Maytinee Kulpanun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
| | - Anon Chotirosniramit
- Department of Surgery, Division of Hepatobilliary Pancreatic Surgery, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
- Clinical Surgical Research Center, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
| | - Sunhawit Junrungsee
- Department of Surgery, Division of Hepatobilliary Pancreatic Surgery, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
- Clinical Surgical Research Center, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
| | - Warangkana Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, 110 Inthawarorot Road, T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand.
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Kuang L, Lin W, Wang D, Chen B. Abnormal coagulation after hepatectomy in patients with normal preoperative coagulation function. BMC Surg 2024; 24:136. [PMID: 38711018 DOI: 10.1186/s12893-024-02406-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND To explore the risk factors for postoperative abnormal coagulation (PAC) and establish a predictive model for patients with normal preoperative coagulation function who underwent hepatectomy. MATERIALS AND METHODS A total of 661 patients with normal preoperative coagulation function who underwent hepatectomy between January 2015 and December 2021 at the First Affiliated Hospital of Sun Yat-sen University were divided into two groups: the postoperative abnormal coagulation group (PAC group, n = 362) and the normal coagulation group (non-PAC group, n = 299). Univariate and multivariate logistic analyses were used to identify the risk factors for PAC. RESULTS The incidence of PAC in 661 patients who underwent hepatectomy was 54.8% (362/661). The least absolute shrinkage and selection operator (LASSO) method was used for multivariate logistic regression analysis. The preoperative international normalized ratio (INR), intraoperative succinyl gelatin infusion and major hepatectomy were found to be independent risk factors for PAC. A nomogram for predicting the PAC after hepatectomy was constructed. The model presented a receiver operating characteristic (ROC) curve of 0.742 (95% confidence interval (CI): 0.697-0.786) in the training cohort. The validation set demonstrated a promising ROC of 0.711 (95% CI: 0.639-0.783), and the calibration curve closely approximated the true incidence. Decision curve analysis (DCA) was performed to assess the clinical usefulness of the predictive model. The risk of PAC increased when the preoperative international normalized ratio (INR) was greater than 1.025 and the volume of intraoperative succinyl gelatin infusion was greater than 1500 ml. CONCLUSION The PAC is closely related to the preoperative INR, intraoperative succinyl gelatin infusion and major hepatectomy. A three-factor prediction model was successfully established for predicting the PAC after hepatectomy.
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Affiliation(s)
- Liting Kuang
- Department of Anesthesiology, the First Afflicted Hospital of Sun Yet-sen University, Guangzhou, 510080, China
| | - Weibin Lin
- Department of Cardiac Surgery, the First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan II Road, Guangzhou, 510080, Guangdong, China.
| | - Dahui Wang
- Department of Anesthesiology, the First Afflicted Hospital of Sun Yet-sen University, Guangzhou, 510080, China
| | - Bin Chen
- Department of Liver Surgery, the First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Zhao R, Xu X, Sun L, Zhang G. Long-term effect of anesthesia choice on patients with hepatocellular carcinoma undergoing open liver resection. Front Oncol 2023; 12:960299. [PMID: 36713494 PMCID: PMC9880263 DOI: 10.3389/fonc.2022.960299] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/28/2022] [Indexed: 01/14/2023] Open
Abstract
Clinical and experimental evidence suggested that anesthesia choice can influence cancer progression and patients' outcomes by modulating tumor microenvironment and tumorigenic pathways. Curative resection is the mainstay of therapy for hepatocellular carcinoma (HCC), which is an intractable disease due to high recurrence and poor prognosis. However, different anesthetics may play different roles in alleviating surgery-induced stress response and inflammatory cytokines release that are considered to be closely associated with proliferation, invasion and metastasis of tumor cells. Propofol, sevoflurane, non-steroidal anti-inflammatory drugs and local anesthetics have shown to exert anti-tumor effect on HCC mainly through regulating microRNAs or signaling pathways, while other inhalational agents, dexmedetomidine and opioids have the potential to promote tumor growth. In terms of anesthetic methods and analgesia strategies, propofol based total intravenous anesthesia and thoracic epidural analgesia could be preferred for HCC patients undergoing open liver resection rather than inhalational anesthesia. Local anesthesia techniques have great potential to attenuate perioperative stress response, hence they may contribute to more favorable outcomes. This review summarized the relations between different anesthesia choices and HCC patients' long-term outcomes as well as their underlying mechanisms. Due to the complexity of molecules interactions and signaling pathways, further studies are warranted to confirm these results so as to optimize anesthesia strategy for HCC patients.
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Affiliation(s)
- Runzhi Zhao
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiyuan Xu
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Sun
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China,*Correspondence: Li Sun, ; Guohua Zhang,
| | - Guohua Zhang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Hebei Cancer Hospital, Chinese Academy of Medical Sciences, Langfang, China,*Correspondence: Li Sun, ; Guohua Zhang,
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Post-hepatectomy venous thromboembolism: a systematic review with meta-analysis exploring the role of pharmacological thromboprophylaxis. Langenbecks Arch Surg 2022; 407:3221-3233. [PMID: 35881311 DOI: 10.1007/s00423-022-02610-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 07/12/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE Patients undergoing hepatectomy are at moderate-to-high risk of venous thromboembolism (VTE). This study critically examines the efficacy of combining pharmacological (PTP) and mechanical thromboprophylaxis (MTP) versus only MTP in reducing VTE events against the risk of hemorrhagic complications. METHODS A systematic review of major reference databases was undertaken, and a meta-analysis was performed using common-effects model. Risk of bias assessment was performed using Newcastle-Ottawa scale. Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 8 studies (n = 4238 patients) meeting inclusion criteria were included in the analysis. Use of PTP + MTP was found to be associated with significantly lower VTE rates compared to only MTP (2.5% vs 5.3%; pooled RR 0.50, p = 0.03, I2 = 46%) with minimal type I error. PTP + MTP was not associated with an increased risk of hemorrhagic complications (3.04% vs 1.9%; pooled RR 1.54, p = 0.11, I2 = 0%) and had no significant impact on post-operative length of stay (12.1 vs 10.8 days; pooled MD - 0.66, p = 0.98, I2 = 0%) and mortality (2.9% vs 3.7%; pooled RR 0.73, p = 0.33, I2 = 0%). CONCLUSION Despite differences in the baseline patient characteristics, extent of hepatectomy, PTP regimens, and heterogeneity in the pooled analysis, the current study supports the use of PTP in post-hepatectomy patients (grade of recommendation: strong) as the combination of PTP + MTP is associated with a significantly lower incidence of VTE (level of evidence, moderate), without an increased risk of post-hepatectomy hemorrhage (level of evidence, low).
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Tzimas P, Lefkou E, Karakosta A, Argyrou S, Papapetrou E, Pantazi D, Tselepis A, Van Dreden P, Stratigopoulou P, Gerotziafas GT, Glantzounis G. Perioperative coagulation profile in major liver resection for cancer: a prospective observational study. Thromb Haemost 2022; 122:1662-1672. [PMID: 35483884 DOI: 10.1055/a-1839-0355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hepatectomy induced coagulation disturbances have been well studied over the past decade. Cumulative evidence supports the superiority of global coagulation analysis compared to conventional coagulation tests (i.e. PT or aPTT) for clinical decision making. Cancer, however, represents an acquired prothrombotic state and liver resection for cancer deserves a more thorough investigation. This prospective observational study was conducted to assess the perioperative coagulation status of patients undergoing major hepatectomies for primary or metastatic hepatic malignancy. Patients were followed up to the 10th postoperative day by serial measurements of conventional coagulation tests, plasma levels of coagulation factors and thrombin generation assay parameters. An abnormal coagulation profile was detected at presentation and included elevated FVIII levels, decreased levels of antithrombin and lag time prolongation in thrombin generation. Serial hematological data demonstrated increased vWF, FVIII, D-dimer, fibrinogen and decreased levels of natural anticoagulant proteins in the early postoperative period predisposing to a hypercoagulable state. The ratio of the anticoagulant protein C to the procoagulant FVIII was low at baseline and further declined postoperatively, indicating a prothrombotic state. Though no bleeding complications were reported, one patient experienced pulmonary embolism while under thromboprophylaxis. Overall, patients with hepatic carcinoma presenting for elective major hepatectomy may have baseline malignancy associated coagulation disturbances, aggravating the hypercoagulable state documented in the early postoperative period.
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Hung HH, Huang CC, Lin MC, Huang ST, Jeng LB. Evaluation of delayed bleeding risks associated with partial hepatectomy: A nationwide population-based propensity score matching study. Int J Surg 2021; 90:105980. [PMID: 34082138 DOI: 10.1016/j.ijsu.2021.105980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/28/2021] [Accepted: 05/25/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is an increased bleeding risk following hepatectomy either due to surgical complications or the nature of liver dysfunction among these patients. For better prevention of delayed bleeding in patients undergoing hepatectomy with different kinds of comorbidities and medications, we examined the risk of major bleeding up to 10 years following hepatectomy. MATERIALS AND METHODS This retrospective study used data from Taiwan's National Health Insurance Research Database. Patients who underwent hepatectomy between 2000 and 2012 were identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes. The non-hepatectomy cohort was defined as patients without any record of hepatectomy. Variables including gender, age, comorbidities, and prescribed medications were matched between the hepatectomy and non-hepatectomy cohorts. RESULTS A total of 1155 patients with hepatectomy and 1155 matched non-hepatectomy subjects were included in this study. The risk of major bleeding was significantly higher in the hepatectomy cohort than that of the non-hepatectomy cohort (adjusted hazard ratio: 1.60). The gastrointestinal tract was the most common site of bleeding among patients with bleeding tendencies (adjusted hazard ratio: 1.93). Compared with the non-hepatectomy cohort, patients who underwent hepatectomy were at greater risk of delayed major bleeding in the first decade following surgery (adjusted hazard ratios ranged from 1.56 to 1.70). CONCLUSION Hepatectomy poses a significant risk of delayed major bleeding, especially in the first decade following surgery. Proper prevention methods and close monitoring for bleeding complications are indicated for patients undergoing hepatic surgeries.
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Affiliation(s)
- Hao-Hsiu Hung
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chao-Chun Huang
- Division of General Surgery, Ministry of Health and Welfare Pingtung Hospital, Pingtung, Taiwan
| | - Mei-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Sheng-Teng Huang
- Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan; School of Chinese Medicine, China Medical University, Taichung, Taiwan; Cancer Research Center for Traditional Chinese Medicine, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan; An-Nan Hospital, China Medical University, Tainan, Taiwan.
| | - Long-Bin Jeng
- Organ Transplantation Center, China Medical University Hospital, Taichung, Taiwan.
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Garg S, Sindwani G, Garg N, Arora MK, Pamecha V, Tempe D. Hypercoagulability on thromboelastography after living donor hepatectomy-The true side of the coin. Indian J Anaesth 2021; 65:295-301. [PMID: 34103743 PMCID: PMC8174592 DOI: 10.4103/ija.ija_1338_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/18/2020] [Accepted: 02/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background and Aims: Coagulation dynamics after donor hepatectomy are complex. Having complete knowledge of the actual changes in the coagulation status during donor hepatectomy is important to prevent complications such as pulmonary embolism, deep vein thrombosis, and bleeding. Hence, the present study aimed to study the coagulation dynamics following open donor hepatectomy both by thromboelastography (TEG) and conventional coagulation tests (CCT). Methods: A total of 50 prospective liver donors were included. TEG and CCT [activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalised ratio (INR), fibrinogen, and platelet counts] were performed for each patient before surgery (baseline), on postoperative day (POD) 0, 1, 2, 3, 5, and 10. Results: TEG showed hypercoagulability in 28%, 38%, 30%, 46%, 42%, and 48% patients; in contrast INR showed hypocoagulability in 58%, 63%, 73%, 74%, 20%, and 0% patients on POD 0,1,2,3,5, and 10, respectively. Patients demonstrating hypercoagulability on TEG had significantly decreased reaction time (P = 0.004), significantly increased maximum amplitude (P < 0.001), and alpha angle value (P < 0.001). Postoperatively, INR, PT, and aPTT values increased significantly, while platelets and fibrinogen levels decreased significantly when compared to their baseline values. There was no coagulation-related postoperative complication in any of the patients. Conclusion: Hypercoagulability after donor hepatectomy is common. TEG showed hypercoagulability and did not show any hypocoagulability as suggested by the CCT. In patients undergoing donor hepatectomy, CCT may not reflect the actual changes incoagulation status and tests such as TEG should be performed to know the correct nature of changes in coagulation following donor hepatectomy.
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Affiliation(s)
- Shankey Garg
- Department of Anaesthesia and Intensive Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Gaurav Sindwani
- Department of Anaesthesia and Intensive Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Neha Garg
- Department of Anaesthesia and Intensive Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Mahesh K Arora
- Department of Anaesthesia and Intensive Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepato-pancreato-biliary Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Deepak Tempe
- Department of Anaesthesia and Intensive Care, Institute of Liver and Biliary Sciences, New Delhi, India
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Koraki E, Mantzoros I, Chatzakis C, Gkiouliava A, Cheva A, Lavrentieva A, Sifaki F, Argiriadou H, Kesisoglou I, Galanos-Demiris K, Bitsianis S, Tsalis K. Metalloproteinase expression after desflurane preconditioning in hepatectomies: A randomized clinical trial. World J Hepatol 2020; 12:1098-1114. [PMID: 33312433 PMCID: PMC7701968 DOI: 10.4254/wjh.v12.i11.1098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/26/2020] [Accepted: 10/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Hepatectomy with inflow occlusion results in ischemia-reperfusion injury; however, pharmacological preconditioning can prevent such injury and optimize the postoperative recovery of hepatectomized patients. The normal inflammatory response after a hepatectomy involves increased expression of metalloproteinases, which may signal pathologic hepatic tissue reformation.
AIM To investigate the effect of desflurane preconditioning on these inflammatory indices in patients with inflow occlusion undergoing hepatectomy.
METHODS This is a single-center, prospective, randomized controlled trial conducted at the 4th Department of Surgery of the Medical School of Aristotle University of Thessaloniki, between August 2016 and December 2017. Forty-six patients were randomized to either the desflurane treatment group for pharmacological preconditioning (by replacement of propofol with desflurane, administered 30 min before induction of ischemia) or the control group for standard intravenous propofol. The primary endpoint of expression levels of matrix metalloproteinases and their inhibitors was determined preoperatively and at 30 min posthepatic reperfusion. The secondary endpoints of neutrophil infiltration, coagulation profile, activity of antithrombin III (AT III), protein C (PC), protein S and biochemical markers of liver function were determined for 5 d postoperatively and compared between the groups.
RESULTS The desflurane treatment group showed significantly increased levels of tissue inhibitor of metalloproteinases 1 and 2, significantly decreased levels of matrix metalloproteinases 2 and 9, decreased neutrophil infiltration, and less profound changes in the coagulation profile. During the 5-d postoperative period, all patients showed significantly decreased activity of AT III, PC and protein S (vs baseline values, P < 0.05). The activity of AT III and PC differed significantly between the two groups from postoperative day 1 to postoperative day 5 (P < 0.05), showing a moderate drop in activity of AT III and PC in the desflurane treatment group and a dramatic drop in the control group. Compared to the control group, the desflurane treatment group also had significantly lower international normalized ratio values on all postoperative days (P < 0.005) and lower serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase values on postoperative days 2 and 3 (P < 0.05). Total length of stay was significantly less in the desflurane group (P = 0.009).
CONCLUSION Desflurane preconditioning can lessen the inflammatory response related to ischemia-reperfusion injury and may shorten length of hospitalization.
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Affiliation(s)
- Eleni Koraki
- Department of Anaesthesiology, “G Papanikolaou” General Hospital, Thessaloniki 57010, Greece
| | - Ioannis Mantzoros
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
| | - Christos Chatzakis
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
| | - Anna Gkiouliava
- Department of Anaesthesiology, “G Papanikolaou” General Hospital, Thessaloniki 57010, Greece
| | - Angeliki Cheva
- Department of Pathology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 54636, Greece
| | - Athina Lavrentieva
- First Department of Intensive Care Unit, "G Papanikolaou" General Hospital, Thessaloniki 57010, Greece
| | - Freideriki Sifaki
- Department of Anaesthesiology, “G Papanikolaou” General Hospital, Thessaloniki 57010, Greece
| | - Helena Argiriadou
- Department of Anaesthesiology and Intensive Care Unit, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | - Isaak Kesisoglou
- Third Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki 54636, Greece
| | | | - Stefanos Bitsianis
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
| | - Konstantinos Tsalis
- Fourth Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki 57010, Greece
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van den Brink DP, Wirtz MR, Neto AS, Schöchl H, Viersen V, Binnekade J, Juffermans NP. Effectiveness of prothrombin complex concentrate for the treatment of bleeding: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:2457-2467. [PMID: 32638483 PMCID: PMC7589201 DOI: 10.1111/jth.14991] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 01/02/2023]
Abstract
Prothrombin complex concentrate (PCC) is increasingly being used as a treatment for major bleeding in patients who are not taking anticoagulants. The aim of this systematic review and meta-analysis is to evaluate the effectiveness of PCC administration for the treatment of bleeding in patients not taking anticoagulants. Studies investigating the effectivity of PCC to treat bleeding in adult patients and providing data on either mortality or blood loss were eligible. Data were pooled using Mantel-Haenszel random effects meta-analysis or inverse variance random effects meta-analysis. From 4668 identified studies, 17 observational studies were included. In all patient groups combined, PCC administration was not associated with mortality (odds ratio = 0.83; 95% confidence interval [CI], 0.66-1.06; P = .13; I2 = 0%). However, in trauma patients, PCC administration, in addition to fresh frozen plasma, was associated with reduced mortality (odds ratio = 0.64; CI, 0.46-0.88; P = .007; I2 = 0%). PCC administration was associated with a reduction in blood loss in cardiac surgery patients (mean difference: -384; CI, -640 to -128, P = .003, I2 = 81%) and a decreased need for red blood cell transfusions when compared with standard care across a wide range of bleeding patients not taking anticoagulants (mean difference: -1.80; CI, -3.22 to -0.38; P = .01; I2 = 92%). In conclusion, PCC administration was not associated with reduced mortality in the whole cohort but did reduce mortality in trauma patients. In bleeding patients, PCC reduced the need for red blood cell transfusions when compared with treatment strategies not involving PCC. In bleeding cardiac surgery patients, PCC administration reduced blood loss.
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Affiliation(s)
- Daan P. van den Brink
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Mathijs R. Wirtz
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Department of Critical Care MedicineHospital Israelita Albert EinsteinSᾶo PauloBrazil
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care MedicineAUVA Trauma Centre SalzburgAcademic Teaching Hospital of the Paracelsus Medical UniversitySalzburgAustria
- Institute for Experimental and Clinical TraumatologyAUVA Research CentreViennaAustria
| | - Victor Viersen
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Jan Binnekade
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Intensive Care MedicineOLVG HospitalAmsterdamThe Netherlands
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Ammar MA, Abdou AMH. Benefits of N-acetylcysteine on liver functions in living donor hepatectomy. Indian J Anaesth 2020; 64:204-209. [PMID: 32346167 PMCID: PMC7179774 DOI: 10.4103/ija.ija_876_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 12/31/2019] [Accepted: 01/25/2020] [Indexed: 01/17/2023] Open
Abstract
Background and Aims: The proportion of patients undergoing living donor liver transplantation is high especially in countries without or with limited cadaver organ sharing programs. The aim of this study was to evaluate the post-hepatectomy effect of using N-Acetylcysteine (NAC) infusion in living donors undergoing donor hepatectomy. Methods: In a prospective randomised non-blinded study, 50 healthy donors were enrolled; following hepatectomy patients were randomised into 2 groups: Group NC receiving NAC 150 mg/kg diluted in 100 ml glucose 5% over 40 minutes, followed by NAC 12.5 mg/kg in 500 ml glucose 5% over 4 hours. This was followed by NAC 6.25 mg/kg for 2 post-operative days, Group C (Control group) received ringer acetate infusion at same rate for 2 days. The primary outcome was serum lactate levels. Secondary outcomes were liver function tests, serum creatinine and urine output on intensive care unit (ICU) admission (0 hr.), after 24 hours and 48 hours, length of ICU stay. Results: Our study revealed significant reduction in serum lactate in Group NC at 0, 24 and 48 hours compared to C group (P = 0.017, 0.002, 0.014). INR values showed significant reduction after 48 hours in Group NC compared to Group C (P = 0.049). Total Bilirubin, ALT, and Creatinine, urine output and ICU stay showed no statistical difference between the 2 groups. Conclusion: The NAC protocol is a safe, cost-effective tool for improvement of post hepatectomy liver function and early stabilisation of the metabolic profile.
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Affiliation(s)
- Mona A Ammar
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amr M Hilal Abdou
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Sharma A, Goel AD, Sharma PP, Vyas V, Agrawal SP. The Effect of Transversus Abdominis Plane Block for Analgesia in Patients Undergoing Liver Transplantation: A Systematic Review and Meta-Analysis. Turk J Anaesthesiol Reanim 2019; 47:359-366. [PMID: 31572985 DOI: 10.5152/tjar.2019.60251] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 01/04/2019] [Indexed: 12/23/2022] Open
Abstract
Objective Ultrasound-guided regional anaesthesia using transversus abdominis plane (TAP) block is a newer and safer method that can be used in patients undergoing liver transplant surgeries. This systematic review and meta-analysis was done to quantify the analgesic potential and opioid-sparing capability of TAP block in these patients. Methods The studies comparing TAP-block to conventional analgesic regimens for liver transplant were searched. The studies evaluating the comparative 24-h morphine consumption during postoperative period in patients undergoing liver transplant surgeries were searched and included as the primary outcome in the analysis. Results We found two randomised controlled trials and two retrospective studies that on meta-analysis showed that TAP block group had significantly lower requirement of morphine (WMD=27.59 mg; 95% CI: 33.47-21.70) at 24 h for pain mitigation. Also, postoperative nausea and vomiting was lower (RR=0.76; 95% CI: 0.47-1.22) but not statistically significant. Conclusion Ultrasound-guided TAP block provides postoperative analgesic efficacy in patients undergoing liver transplant surgeries. This study was registered in International prospective register of systematic reviews [PROSPERO: CRD42018094595].
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Affiliation(s)
- Ankur Sharma
- Department of Trauma and Emergency (Anaesthesiology), All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Akhil Dhanesh Goel
- Department of Community and Family Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Prem Prakash Sharma
- Department of Community and Family Medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
| | - Varuna Vyas
- Department of Paediatrics, All India Institute of Medical Sciences (AIIMS), Jodhpur, Rajasthan, India
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