The Clinical Research Of Goal-directed Fluid Therapy In Living Donor Right Hepatectomy(LDRH) For Adult-to-adult Liver Transplantation

Objective: Our study aims to compare the effect of stroke volume variation(SVV), left ventricular ejection time correct(LVETc) and controlled low central venous pressure(CLCVP) on the fluid optimization of patients undergoing living donor hepatectomy and to provide a relatively safe liquid therapy clinically.Methods: A total of 60 adult living donor liver transplant donors admitted to Tianjin First Center Hospital were enrolled, including 38 males and 22 females, ASAⅠgrade, aged 32 to 54 years old, weighing 56 ~ 88 kg. Patients were randomly assigned into three groups :CLCVP group, SVV group, and LVETc group, each including 20 patients. In CLCVP group, CVP was maintained 0~5cm H2 O to limit liquid supplement; in SVV group, SVV was kept to 11 ~ 13% as the target; and for LVETc group, Sinclair’s method was adopted that fluid was input to keep corrected left ventricular ejection time(LVETc) got by TEE between 0.35 s to 0.4s. Measurements of average invasive arterial pressure(MAP), heart rate(HR) and cardiac output(CO) were performed at these times: before induction of anesthesia(T0, baseline), immediately before incision(T1), 30 min after the opening of the abdominal cavity(T2), the hepatectomy was achieved(T3) and the close of abdominal cavity(T4); Arterial blood gas analysis was performed to investigate the level of serum lactic acid at these times: before the induction of anesthesia(T0, baseline), the hepatectomy was achieved(T3), the close of abdominal cavity(T4) and 1, 3days after surgery(T5~6); The values of serum alanine aminotransferase(ALT), aspartate aminotransferase(AST), total bilirubin(TBIL), direct bilirubin(DBIL), blood urea nitrogen(BUN) and creatinine(Cr), and the blood Hb and Hct levels were measured at these times: before the induction of anesthesia(T0, baseline) and 1, 3, 5 days after surgery(T5~7). The time of hepatectomy and operation, the intraoperative amount of fluid supplement, blood loss and urine output were recorded. We also recorded the postoperative ICU residence time, the occurrence of adverse events including blood transfusion, negative hemodynamic fluctuations and myocardial ischemia during the petioperotive periodResults: 1 Basic data: No significant differences in age, gender ratio, height, weight, liver resection time and total operation time among the three groups of patients were observed.(P>0.05) 2 Hemodynamics:2.1 HR: Compared with baseline, HR was decreased before the incision in all the three groups(P <0.05). In the CLCVP group a increase in heart rate from baseline occurred when the hepatectomy was achieved. It was higher than that of LVETc group and SVV group(P < 0.05) and decreased to the baseline level when the abdominal cavity was closed. In the LVETc group and SVV group HR is decreased to the baseline level at 30 min after the opening of the abdominal cavity(P > 0.05). 2.2 MAP: Compared with baseline, MAP was decreased before the incision in all the three groups(P <0.05). In the CLCVP group MAP was decreased compared to baseline from the incision to the hepatectomy was achieved(P < 0.05). It was lower than that of LVETc group and SVV group(P < 0.05) and increased to the baseline level when the abdominal cavity was closed. In the LVETc group and SVV group MAP was increased to the baseline level at 30 min after the opening of the abdominal cavity(P> 0.05). 2.3 CO: Compared with baseline, CO was decreased before the incision in all the three groups(P <0.05). In the CLCVP group CO was also decreased from 30 min after the incision to the hepatectomy was achieved(P < 0.05). And it was lower than that of LVETc group and SVV group(P < 0.05). No significant differences were observed in other data(P > 0.05). 3 Lactic acid and biochemical variables 3.1 Lactic acid: Compared with baseline, the level of lactic acid was increased from the hepatectomy was achieved to the close of abdominal cavity in all the three groups(P <0.05) and it was higher in CLCVP group than that of LVETc group and SVV group(P < 0.05). In the LVETc group and SVV group the level of lactic acid was decreased to the baseline level at first day after surgery while at the third day after surgery in CLCVP group. 3.2 Biochemical variables: Compared with baseline, the values of serum ALT, AST, TBIL and DBIL were increased after surgery(P <0.05). The values of serum ALT and AST in CLCVP group were higher than that of LVETc group and SVV group at 1,3 days after surgery(P < 0.05). No significant differences were observed in other data(P > 0.05). 4 Hb and Hct: Compared with baseline, the values of blood Hb and Hct were decreased after surgery(P <0.05). In the LVETc group the values of blood Hb and Hct were lower than that of CLCVP group and SVV group at first day after surgery(P < 0.05). 5 The amount of blood loss and urine output and fluid supplemen: Compared withCLCVP group, no significant differences were observed in the amount of blood loss and urine output and hydroxyethyl starch supplement of SVV group(P > 0.05), while that of LVETc group was increased(P <0.05). 6 Adverse events and the length of ICU stay: the occurrence of hemodynamic negative fluctuations in LCVP group was more than that in SVV group and LVETc group. There were no significant differences in the extubation time and the length of ICU stay among the three groups(P > 0.05).Conclusion: Guiding fluid therapy by keeping SVV between 11% and 13% has the same effect of blood conservation to CLCVP in patients undergoing living donor hepatectomy. However, SVV monitoring is associated with better liver perfusion than CLCVP. Guiding fluid administration by monitoring LVETc could keep stable hemodynamics and optimize intravascular volume, however, the risk of bleeding and blood transfusion were also increased.