| Background There are dramatic hemodynamic change during orthotopic liver transplant(OLT) due to pathophysiological change and surgical manoeuvre, which may result in reperfusion syndrome and compromise perioperative safety. Thus, monitoring and management of hemodynamic variables is one of the focus of perioperative care of OLT. Many monitoring technique and surgical procedure has been developed for this purpose recently. My hypothesis is that intraoperative monitoring using TEE and EV1000_Flo Trac together can be effectively used for management of hemodynamic fluctuation; and pretreatment before opening can reduce the time of anhepatic phase and reperfusion syndrome. In my thesis I have used TEE and EV1000 monitoring to guide the fluid management and its efficacy on hemodynamic improvement. The effect of pretreatment before portal vein opening on intraoperative hemodynamics,renal function, neural function and other complications.Materials and methods:I. The application of TEE and EV1000_Flo Trac during liver transplant Fifty Classic OLT patients were randomized into Swan-Ganz monitoring group(Group S) and TEE with EV1000 group(Group T). Hemodynamic variables were recorded at 1 h after incision in preanhepatic phase(T1), 2 min after IVC and portal vein cross clamp in anhepatic phase(T2), end of anhepatic phase(T3), reperfusion 2min(T4), reperfusion 15 min(T5), reperfusion 30 min(T6) and end of surgery(T7).The incidence and duration of reperfusion syndrome, TEE readings and related complications were also recorded.II. The influence of pretreatment before portal vein opening and TEE,EV 1000 monitoring on hemodynamic during OLT, renal function and neural function.Forty OLT patients were randomized into pretreatment group(Group T) and routine group(Group C).Group T: 1) open suprahepatic inferior vena cava(SVC) after anastomosis but before the anastomosis of portal vein; 2) take 200 ml blood from the portal vein of donor and receptor respectively.Goup C: SVC, portal vein were routinely sutured. Only 100-200 ml blood were taken from the donor and receptor portal vein and vessels were opened in sequence.Hemodynamic variables and IL-6, IL-8 levels were recorded at 1 h after incision in preanhepatic phase(T1), 10 min after IVC and portal vein cross clamp(T2), end of anhepatic phase(T3), reperfusion 5 min(T4), reperfusion 1h(T5) and end of surgery(T6). The incidence and duration of reperfusion syndrome, TEE readings and postand intraoperative renal function(β2 MG、BUN、CCr)and postoperative delirium were also recorded.Results I. The application of TEE and EV1000_Flo Trac during liver transplant1) Comparison of hemodynamicsThe decrease of CCO at T2 and T4 was faster in Group T than in Group S, and no significant difference was found after T5(P<0.05). The change in RVEDV, EF at T2,T4 was observed earlier by TEE than Swan-Ganz. There were correlations between the two monitoring methods2)Comparison of intraoperative conditions and perioperative adverse effect The quantity of bicarbonate used was less in Group T(P<0.05). Less patients developed hypotension after reperfusion in Group T(P<0.05). One patient in Group S experienced cardiac arrest, but there were no significant differences between two groups.3)Cardiac function during surgery monitored by TEE LVEDV and tricuspid annular displacement were reduced at T2 compared to T1.(P<0.05)4)Intubation and length of ICU stay No significant deifferences(P>0.05).II. The influence of pretreatment before portal vein opening and TEE,EV 1000 monitoring on hemodynamic during OLT, renal function and neural function.1)comparison of hemodynamics There were significant differences in CCO,SVV,MAP,HR and CVP at T2,T4 between the two groups(P<0.05). Only CVP was significant different between two groups at T6.2) Comparison of intraoperative conditions and perioperative adverse effect Less bicarbonate, blood transfusion and fluid was administered in Group T(P<0.05).The incidence of delirium, arrhythmia and myocardial ischemia was also lower in Group T(P<0.05).3)Blood gas and vasoactive agent The potassium concentration at T4 was higher in Group C and also higher than that at T1 in both groups. BE declined gradually during the surgery. But was lower at other time points than T1 in both groups(P<0.05), and group C is higher than group T at T3, T4, T5. The dosage of adrenaline and phenylephrine was higher in groupc than in group T at T3 and T4 and also higher than T1 in both groups(P<0.05).4) Change in BUN、CCr、β2 MG、IL-6、IL-8CCr: It was higher in Group C than Group T at the end of surgery and 1d after surgery. It was higher at the end of surgery 1d and 2d after surgery in both groups,and recovered 3 d after surgery.BUN: It was higher in group C at all time points other than preoperative. It was higher at other time points than T1.β2 MG: It was higher in group C at T3,T4,T5. It was higher at other time points than T1(P<0.05).IL-6、IL-8 was higher in group C at T4,T5,T6. IL-8 was also higher in group C at T3(P<0.05). It was higher at other time points than T1 in both groups(P<0.05).Conclusions:1. TEE monitoring can accurately reflect the hemodynamic changes during OLT and the reacted quicker than Swan-Ganz catheter during anhepatic phase and reperfusion.2. EV1000_Flo Trac detected hemodynamic changes quicker than Swan-Ganz during anhepatic phase and the beginning of reperfusion and had good agreement with Swan-Ganz without complications related to insertion of pulmonary catheter.Thus, EV1000 can be used safely for fluid management during OLT.3. TEE together with EV1000_Flo Trac monitoring used during OLT can reduce errors and provide accurate data for guiding therapy without increased difficulty and complication.4. The pretreatment of opening immediately after anastomosis of inferior vena cava can improve hemodynamic condition during anhepatic and reperfusion phase thus decrease reperfusion syndrome. Pretreatment decrease the impairment in renal function due to OLT. Pretreament is useful for decrease of delirium after OLT. |
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