Kwok-Wai Cheng

Bispectral Index Monitoring in Healthy, Cirrhotic, and End-Stage Liver Disease Patients Undergoing Hepatic Operation

The purpose of this study was to assess factors influencing the end-tidal concentrations of isoflurane within a bispectral index (BIS) range of 45-55 among healthy live liver donors (n = 11), chronic hepatitis B patients undergoing hepatectomy hepatocellular carcinoma (n = 10), and end-stage liver disease patients undergoing liver transplantation (n = 7). Patients data collected prospectively were compared among the groups using one-way analysis of variance as well as univariate and multivariate techniques. The results showed that end-stage liver disease patients required the least end-tidal isoflurane concentration. Patients with hepatocellular carcinoma with cirrhosis required intermediate end-tidal isoflurane concentrations; healthy live liver donors required the highest end-tidal isoflurane concentrations to provide sufficient anesthetic depth, as monitored by a target BIS (range, 45-55). Upon multivariate analysis, liver function was the only significant factor influencing the likelihood of lowering the end-tidal isoflurane concentration by 4 hours after anesthesia induction (P = .026). In conclusion, we recommend a preset target BIS within the range of 45-55 to monitor the depth of anesthesia during partial hepatectomy and liver transplantation because end-tidal isoflurane concentration requirements are different for patients with various liver status. This strategy may protect the patients from intraoperative recall or anesthesia over-depth as a consequence of insufficient or overdose of anesthesia, respectively.

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.

Predictive factors associated with re-exploration for hemostasis in living donor liver transplantation.

BACKGROUND After liver transplantation (LT), re-exploration of the abdomen to check for bleeding is sometime required. Our study aimed to identify the predictive factors by analysis of preoperative and intraoperative presentations that may impact the re-exploration for hemostasis. MATERIAL/METHODS We selected 522 consecutive recipients from the Liver Transplant Program database and medical records between January 1, 1994 and December 1, 2009 in our hospital. Demographic data (age, sex, body mass index, weight, MELD score), preoperative laboratory tests (Hb, platelet, albumin, bilirubin, INR, APTT), and intraoperative presentations (ascites and blood loss, crystalloids, 5% albumin infused, blood products used (such as LPRBC, RBC, FFP, platelet, cryoprecipitate), urine output, Hb at end of operation, and anesthesia) were collected for primary comparison. Potential predictors found by univariate comparison at p<0.1 were put into a multiple binary logistic regression model. RESULTS Thirty-eight (7.3%) recipients required re-exploration for hemostasis after LDLT; 80% needed re-exploration only once. In univariate analysis, recipients transfused with FFP >10 ml/kg had a 4.2-fold increased risk of re-exploration (p<0.001). Thirteen potential predictors by univariate comparison at p<0.1 were selected into a multiple binary logistic regression. Fresh frozen plasma (FFP) transfused was the sole predictor. CONCLUSIONS Each elevation of 1ml of transfused FFP per kg is associated with a 1.033-fold increased incidence of re-exploration for hemostasis. Patients transfused with more than 10 ml/kg FFP during LT require more intensive management within 72 hours due to increase risk of postoperative bleeding.

Intraoperative blood and fluid administration differences in primary liver transplantation versus liver retransplantation.

OBJECTIVES Liver retransplantation (Re-LT) is the effective therapy for irreversible liver graft failure after primary liver transplantation (LT). The challenges faced by the operative team in the Re-LT setting have been seldom elucidated. Our aim is to analyze the differences in fluid management in primary LT and Re-LT during the surgical procedure. METHODS The anesthesia charts of 16 patients who underwent both primary LT and Re-LT at our center in the space from October 1995 to May 2009 were analyzed. Group 1 (GI) consisted of patients who underwent primary LT, whereas patients in Group 2 (GII) were patients in GI but underwent Re-LT. GI was further divided into two subgroups depending on whether they had previous abdominal surgery before primary LT (GIB) or not (GIA). Wilcoxon signed-ranks test was used to compare GI and GII, and GIA and GIB. A p value less than 0.05 was regarded as significant. Data were given as mean ± standard deviation. RESULTS Blood loss was significantly increased from 48.9 ± 106 mL/kg in GI to 251.5 ± 242 mL/kg in GII. Consequently more blood products, crystalloids, sodium bicarbonate, calcium chloride, and neosynephrine were required to support the hemodynamics in GII. In GI, GIB tended to bleed more and required more blood transfusions than GIA. CONCLUSION More bleeding is expected in Re-LT than primary LT. Additional anesthetic personnel, more intravenous lines, and blood and blood products should be readily available to deal with the emergent fluid and hemodynamic resuscitations in anesthesia for Re-LT.

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.

Rhabdomyolysis after liver transplantation: a case report.

Our aim was to present the case of a pediatric biliary atresia patient who experienced rhabdomyolysis with severe cardiac arrhythmias associated with hyperkalemia, metabolic acidosis, and myoglobulinemia during liver transplantation. A 5-year-old girl, weighing 16.5 kg, with end-stage liver disease due to biliary atresia underwent living donor liver transplantation. A sudden onset of atrial fibrillation with rapid ventricular response was noted during the transplantation. The cardiac arrhythmia was associated with hyperkalemia, metabolic acidosis, and myoglobulinemia. Rhabdomyolysis was suspected. Hyperkalemia and metabolic acidosis were not corrected despite treatment with 10 mL of 50% glucose plus 6 U of regular insulin in 4 succeeding boluses and 110 mEq sodium bicarbonate before sending the patient to the intensive care unit. A corresponding decrease and normalization in serum potassium and correction of metabolic acidosis were noted as responses to a single dose of intravenous (20 mg) dantrolene. The patient was extubated 5 days after transplantation. The kidney function remained within normal limits during the rhabdomyolysis and the entire hospital stay. The patient was discharged 7 weeks later and is surviving with the original liver graft and satisfactory kidney function to date.

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.