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Effect of Right Ventricular Dysfunction on Dynamic Preload Indices to Predict a Decrease in Cardiac Output After Inferior Vena Cava Clamping During Liver Transplantation

BACKGROUNDnDynamic preload indices such as stroke volume variation (SVV) and pulse pressure variation (PPV) have yielded false-positive results in patients with right ventricular (RV) dysfunction. We therefore assessed the effect of RV dysfunction on dynamic indices to predict the decrease in cardiac output (CO) during liver transplantation.nnnMETHODSnHemodynamic parameters were measured before and after inferior vena cava (IVC) clamping in 52 recipients. The RV dysfunction was defined as an RV ejection fraction (RVEF) ≤ 30%. The area under the receiver operating characteristic curve (AUC) sufficient to detect changes in CO (ΔCO) ≥ 20% after IVC clamping in recipients was calculated.nnnRESULTSnRecipients with RVEF ≤ 30% did not show significant increases in SVV or PPV despite having ΔCO ≥ 20%. In recipients with RVEF > 30%, the threshold value and AUC of SVV predicting a decrease in CO were 10% and 0.755 (compared with an AUC of 0.5, P = .011), respectively, whereas those for PPV were 10% and 0.767 (P = .007), respectively. However, in recipients with RVEF ≤ 30%, the threshold value and AUC of SVV were 10% and 0.638 (P = .305), respectively, whereas those for PPV were 12% and 0.684 (P = .159), respectively.nnnCONCLUSIONSnThese results suggest that dynamic preload indices may not be sufficiently sensitive to detect a CO decrease in liver transplant recipients with RV dysfunction, emphasizing the importance of evaluating RV function when determining the predictability of dynamic indices.

Increased B-Type Natriuretic Peptide During Liver Transplantation: Relationship to Invasively Measured Hemodynamic Parameters

BACKGROUNDnThe role of B-type natriuretic peptide (BNP) concentration in predicting cardiac dysfunction has been extensively investigated in many clinical conditions. Little is known, however, about its relationships with hemodynamic parameters from right heart catheterization in patients undergoing liver transplant surgery.nnnMETHODSnWe retrospectively evaluated 525 patients who underwent liver transplantation. Hemodynamic variables from a Swan-Ganz catheter and BNP concentrations were measured 1 hour after induction of general anesthesia. Patients were stratified by quintiles of BNP concentrations. Univariate and multivariate logistic regression analysis were used to identify hemodynamic parameters associated with BNP ≥ 135 pg/mL, a cutoff point for the 5th quintile.nnnRESULTSnUnivariate analysis showed that factors significantly associated with BNP ≥ 135 pg/mL included model for end-stage liver disease (MELD) score, diastolic blood pressure, mean pulmonary artery pressure, pulmonary capillary wedge pressure (PCWP), cardiac index, right ventricular end-diastolic volume index (RVEDVI), systemic vascular resistance index, pulmonary vascular resistance index (PVRI), and right ventricular stroke work index. Multivariate analysis revealed that MELD score (odds ratio [OR] = 1.059, P < .001), PCWP (OR = 1.116, P = .026), RVEDVI (OR = 1.010, P = .009), and PVRI (OR = 1.009, P = .002) were independent determinants of BNP ≥ 135 pg/mL.nnnCONCLUSIONSnSeverity of liver disease, preload dependent hemodynamic parameters, and pulmonary vascular resistance were found to be significantly associated with increased BNP concentration, reinforcing the utility of BNP as a marker of cardiac strain and ventricular volume overload in liver failure patients undergoing liver transplant surgery.

Change of QT variability index during general anesthesia

Background The QT variability index (QTVI)–a non-invasive measure of beat-to-beat QT interval (QTI) fluctuations–is related to myocardial repolarization lability. The QTVI represents the relationship between QTI and the RR interval. Elevated QTVI is associated with an increased risk of malignant ventricular arrhythmias and sudden death. We investigated the influence of general anesthesia and tourniquets on the QTVI. Methods We studied fifty patients who received total knee replacement arthroplasty under sevoflurane anesthesia. We measured QTI, corrected QTI (QTc), T-wave peak-to-end interval (TPE), QTVI, and heart rate variability. All variables were calculated at baseline (B), 30 min after general anesthesia (A), 30 min (TQ1) and 60 min (TQ2) after tourniquet inflation, and at tourniquet deflation (TQR). Results Prolongation of QTI was detected at all times, and QTc was significantly prolonged TQR. TPE was unchanged during general anesthesia. The QTVI was significantly decreased and more negative during anesthesia and tourniquet inflation. After deflation of the tourniquet, the QTVI was restored to preanesthetic values. Low frequency (LF) was significantly decreased during general anesthesia, but high frequency (HF) was somewhat maintained, except at TQ2. The LF/HF ratio was significantly decreased at A and TQ2. Conclusions Sevoflurane based general anesthesia induced repolarization stability and, more negativity of the QTVI, in patients undergoing total knee replacement arthroplasty.

General anesthesia in a patient with multicentric Castleman's disease: a case report

Castlemans disease (CD) is a rare lymphoproliferative disorder of undetermined etiology. Unicentric Castlemans disease is confined to a single lymph node; it is usually asymptomatic though sometimes has local manifestations related to mass effects. In contrast, multicentric Castlemans disease (MCD) typically presents with lymphoid hyperplasia at multiple sites; it is associated with systemic symptoms and abnormal laboratory findings, with a less favorable prognosis. In case of anesthesia in CD, an exhaustive preanesthetic evaluation is essential to identify associated clinical manifestations which may influence the management of the anesthesia. Perioperative careful monitoring and proper anesthetic management are both important. We report a case of general anesthesia with anesthetic management in a patient with MCD that has not been documented in the literature.