C.-J. Huang

Pain Management of Living Liver Donors With Morphine With or Without Ketorolac

BACKGROUND To compare the efficacy and dose requirements for intravenous (IV) patient-controlled analgesia (PCA) with morphine only versus morphine with ketorolac for living liver donors after partial hepatectomy. PATIENTS AND METHODS Eighty living liver donors who had undergone partial hepatectomy received 3 days of IV PCA for postoperative pain control. Some were prescribed a PCA with morphine alone (group I) or morphine with ketorolac (group II), while both had a rescue dose of IV fentanyl (25 μg). The daily consumption of morphine, pain score, and frequency of rescue fentanyl doses were compared retrospectively using the Mann-Whitney U test and the incidence of side effects with chi-square tests; a P value of .05 was regarded as significant. All the data are shown as mean values±standard deviations. RESULTS The 80 subjects were distributed as 57 group I and in 23 group II patients. The daily consumption of morphine, Visual Analogue Scale (VAS) and side effects were not different between the groups, but group II required significantly fewer rescue doses to achieve pain relief. CONCLUSION Both regimens provided acceptable pain control with daily VAS less than 3. The use of ketorolac in the PCA did not reduce the daily total morphine requirements with a similar incidence of side effects but a significantly reduced requirement for rescue doses, which subsequently reduced the work load of personnel in the pain control service.

Comparison of postoperative morphine requirements in healthy living liver donors, patients with hepatocellular carcinoma undergoing partial hepatectomy, and liver transplant recipients.

OBJECTIVE To retrospectively evaluate postoperative morphine requirements in healthy living donors undergoing partial hepatectomy and patients with end-stage hepatocellular carcinoma or end-stage liver disease undergoing liver transplantation. PATIENTS AND METHODS The study included all patients who received intravenous patient-controlled analgesia after partial hepatectomy or liver transplantation from May 2008 to February 2009. Patients were divided into 3 groups according to type of surgery: group 1, healthy living liver donors undergoing graft procurement; group 2, patients with liver cirrhosis due to chronic hepatitis B virus or hepatitis C virus infection and hepatocellular carcinoma undergoing hepatectomy; and group 3, patients with end-stage liver disease undergoing living-donor liver transplantation. Data including patient age, morphine use, and visual analog scale score on postoperative days (PODs) 1, 2, and 3 were compared between groups using 2-way analysis of variance. P<.05 was considered significant. Values are given as mean (SD). RESULTS Morphine requirement was significantly lower only in group 3 on POD 1. No difference in visual analog scale score between groups was observed postoperatively. CONCLUSION Although others have reported decreased morphine requirements on PODs 1, 2, and 3, our results indicated that morphine requirements were significantly less only on POD 1.

Hemodynamic Changes During the Anhepatic Phase in Pediatric Patient With Biliary Atresia Versus Glycogen Storage Disease Undergoing Living Donor Liver Transplantation

OBJECTIVE The aim of this study was to compare the hemodynamic changes caused by clamping of the inferior vena cava and portal vein in biliary atresia (BA) versus glycogen storage disease (GSD) patients undergoing living-donor liver transplantation (LDLT) without venovenous bypass. METHODS We reviewed retrospectively the anesthesia charts of pediatric LDLT patients. Age, weight, height, blood loss, blood product use and fluid replacement between groups were compared with Mann-Whitney test, and systolic blood pressure (SBP), heart rate (HR), central venous pressure (CVP) before clamping of the inferior vena cava, and 4 measurements during anhepatic phase and 5 minutes after reperfusion were compared with analysis of variance. RESULTS One hundred four BA patients (GI) and 12 GSD patients (GII) showed mean total blood loss among GI to be more than among GII, but the blood products and crystalloids infused during the operation were not significantly different. The changes of SBP, HR, and CVP after clamping of the IVC were significantly different between groups. CVP of GII was lower than GI, indicating that venous return among GII was more affected, subsequently showing lower SBP and higher HR. CONCLUSIONS Total clamping of the inferior vena cava resulted a greater decrease in CVP in GII with subsequently lower SBP and faster HR compared with GI.

Low-Dose Dantrolene Is Effective in Treating Hyperthermia and Hypercapnia, and Seems Not to Affect Recovery of the Allograft After Liver Transplantation: Case Report

Dantrolene is the drug of choice in treatment of malignant hyperthermia. However, dantrolene is hepatotoxic; thus prolonged use is not recommended in patients with active hepatic disease such as acute hepatitis or active cirrhosis because it may result in fatal hepatic failure. Use of dantrolene in a patient with end-stage liver disease undergoing liver transplantation (LTx) in whom suspected malignant hyperthermia developed has been reported rarely. Its effect on the liver allograft, which has sustained cold, warm, and reperfusion injuries, is currently unknown. We report a case in which low-dose dantrolene administered intravenously during LTx was effective in treating hyperthermia, hypercapnia, and hyperkalemia. Furthermore, its reported hepatotoxic effect seemed to not affect recovery of the allograft after LTx.

Decreased Fresh Gas Flow Cannot Compensate for an Increased Operating Room Temperature in Maintaining Body Temperature During Donor Hepatectomy for Living Liver Donor Hepatectomy

BACKGROUND The purpose of this study was to compare the effect of various combinations of fresh gas flow (FGF) of anesthesia and different ambient operation room temperatures (ORT) on changes in nasopharyngeal temperature (NT) among living donors undergoing partial hepatectomy. METHODS The anesthesia records of 167 patients were reviewed retrospectively. The patients were allocated into 4 groups: GI (n=37): isoflurane in 2 L FGF and at typical ambient ORT (19 degrees C-21 degrees C); GII (n=11) isoflurane in 1 L FGF and 1 L air at typical ORT; GIII (n=31) isoflurane in 0.5 L FGF at typical ORT; and GIV (n=88) isoflurane in 0.5 L FGF at ORT of 24 degrees C. The changes in NT were compared using a two-way repeated measure analysis of variance (ANOVA) followed by Bonferroni post hoc tests. RESULTS Changes of NTs of GIV were significantly higher compared with the other 3 groups, whereas the changes of NTs were the same among GI, GII, and GIII. CONCLUSION FGF of different volumes seemed to have no significant effect on intraoperative changes of NT in regular ORT. Low-flow anesthesia combined with ORT of 24 degrees C provided significantly higher NTs at all measured points compared with GI, GII, and GIII.

Retrospective Cohort Study to Compare Anesthesia in Living Donor Liver Transplantation Recipients Who Received Single and Dual Liver Grafts

OBJECTIVE Dual graft living donor liver transplantation (LDLT) is an alternative way to overcome small-for-size syndrome in LDLT. Surgical technique and outcome of using dual grafts have been reported, but there are no reports regarding anesthetic management. The aim of the current study is to compare the anesthetic management of single graft and dual graft liver transplantation. METHODS AND PATIENTS Anesthesia records of 24 single graft liver transplantation recipients (GI) and 6 dual graft recipients (GII) were reviewed, analyzed, and compared retrospectively. Patient characteristics and intraoperative data between groups were compared with Mann-Whitney t test and Fishers exact test where appropriate. P value less than .05 was regarded as significant. RESULTS Patient characteristics and most of the intraoperative data were similar between groups. Significant difference was noted in the total anesthesia time and the anhepatic time. Both times were significantly longer in GII compared to GI. CONCLUSION Dual graft living donor liver transplantation is surely a technically more challenging and demanding procedure. Therefore the total anesthesia time is longer, especially the anhepatic phase, because there are more graft vessels to be reconstructed before reperfusion. Overall the anesthetic management in terms of blood transfusion, fluid administration, sodium bicarbonate, calcium supplement, and the number of patients requiring fractional diluted noradrenaline support for maintenance of acceptable hemodynamic were not much different between the 2 groups.

Anesthesia management and fluid therapy in right and left lobe living donor hepatectomy

OBJECTIVE Right lobe living donor hepatectomy poses a greater risk for the donor in relation to blood loss. The aims of this study were to compare anesthetic and intraoperative fluid management in right and left lateral segment living donor hepatectomy. PATIENTS AND METHODS The anesthesia records of living donor hepatectomy patients were retrospectively reviewed. Donor age and weight, anesthesia time, central venous pressure, blood loss, blood product transfusion, intravenous fluids used, doses of furosemide, and urine output were compared and analyzed between groups using the Mann Whitney U test. RESULTS Forty-six patients underwent living donor left lateral segment hepatectomy (Group I); while 31 patients underwent right lobe hepatectomy (Group II). The mean blood loss in Group II was significantly higher compared to Group I (118 ± 81 mL vs 68 ± 64 mL), but clinically such amount of blood loss was not high enough to affect the hemodynamics. The fluid management was therefore not meaningfully different between the two groups. No blood transfusions or colloid infusions were required for either group. Urine output, hemoglobin changes, blood urea nitrogen, and serum creatinine pre- and postoperatively were not significantly different between groups. CONCLUSIONS As long as blood loss is minimal, we found no difference in the anesthetic management and fluid replacements between right and left lateral segment living donor hepatectomy.

Eye Protection in Liver Transplantation Patients under General Anesthesia

BACKGROUND Opsite (Smith & Nephew, Hull, UK) is widely used in wound care but its use in eye protection against corneal abrasion during major surgery is rarely reported. The purpose of the current study is to compare the effectiveness of using Opsite in eye protection with either wet gauze alone or with wet gauze following application of eye ointment in patients undergoing living donor liver transplantation (LDLT). METHODS This is a prospective, double-blinded, randomized controlled trial. Forty-one patients undergoing liver transplantation were enrolled. One eye of each patient was protected with sterile gauze soaked with normal saline solution and covered with Opsite. Duratears (ALCON, Fort Worth, Tex, United States) ointment was applied to the other eye before covering it with sterile wet gauze and Opsite (ointment group). The corneal examination was carried out after fluorescein staining before and at the end of surgery by the same doctor. A Student t-test and a χ2 test were used for the statistical analyses. RESULTS Forty-one patients with 82 eyes were observed in this study. No corneal epithelial defects were found in either the normal saline group or the ointment group. CONCLUSION Opsite combined with wet gauze with or without additional eye ointment provided 100% protection against corneal abrasion in patients undergoing LDLT.

Clinical Beneficial Effects of Using Crystalloid only in Recipients of Living Donor Liver Transplantation

Objective: Liver transplantation (LT) is a major surgery associated with intraoperative massive fluid shift, which is usually replaced by crystalloid, 5% albumin (colloid) and blood products. We studied 15 patients from 477 consecutive recipients of adult living donor liver transplantation. Each patient received crystalloid only during LT. Whether LT provides any clinical benefit is not clear and must be determined. Methods and Patients: The anesthesia records of 477 adult LDLT were reviewed retrospectively. The patients were divided into three groups according to the fluids received. Group I (GI) had received blood products, 5% albumin and crystalloid, group II (GII) received 5% albumin and crystalloid, and group III (GIII) received crystalloid only. The characteristic intraoperative variable and postoperative acute rejection and survival rate were compared amongst groups by using One Way ANOVA post hoc with Bonferroni and by Ficher’s Exact test and Chi-square χ2 test. Results and Conclusions: GIII had less intraoperative ascites and blood loss; they also had more stable hemodynamics. Furthermore, they could be extubated significantly earlier than GI, and the one- and three-year survival rates were excellent, with 100% in GIII, while that of GI and GII were 94.1%, 90.5% and 98.6%, 94.5%, respectively.

Effect and Outcome of Intraoperative Fluid Restriction in Living Liver Donor Hepatectomy

Background The purpose of this study was to evaluate the effect and outcome of intraoperative fluid restriction in living liver donor hepatectomy, regarding changes in intraoperative CVP levels, blood loss, and postoperative renal function. Material/Methods The charts of 167 patients were reviewed and analyzed retrospectively. Intraoperative central venous pressure levels, blood loss, fluids infused, and urine output per hour, before and after the liver allograft procurement, were calculated. Perioperative renal functions were also analyzed. Results Fluid infused before and after liver allograft procurement was 3.21±1.5 and 9.0±3.9 mL/Kg/h and urine output was 1.5±0.7 and 1.8±1.4 mL/Kg/h, respectively. Intraoperative estimated blood loss was 91.3±78.9 mL. No patients required blood transfusion. Their preoperative and postoperative hemoglobin were 12.3±2.7 and 11.7±1.7 g/dL. CVP levels decreased gradually from 10.4±3.0 to a low of 8.1±1.9 mmHg at the time of transection of the liver parenchyma. Renal functions were not significantly affected based on the determination of BUN and creatinine levels. Conclusions The methods used to lower CVP are moderate and slow, with 2 main goals achieved: minimal blood loss (91.3±78.9 ml) and no blood transfusion. Furthermore, it did not have any negative effect on renal function.