Intraoperative fluid management during orthotopic liver transplantation

Abstract

Objective: To assess clinical safety of a low central venous pressure (CVP) fluid management strategy in patients undergoing liver transplantation. Design: Retrospective record review comparing 2 transplant centers, one using the low CVP method and the other using the normal CVP method. Setting: University-based, academic, tertiary care centers. Participants: Patients undergoing orthotopic cadaveric liver transplantation. Interventions: Each center practiced according to its own standard of care. Center 1 maintained an intraoperative CVP <5 mmHg using fluid restriction, nitroglycerin, forced diuresis, and morphine. If pressors were required to maintain systolic arterial pressure >90 mmHg, phenylephrine or norepinephrine was used. At center 2, CVP was kept 7 to 10 mmHg and mean arterial pressure >75 mmHg with minimal use of vasoactive drugs. Measurements and Main Results: Data collected included United Network for Organ Sharing status, surgical technique, intraoperative transfusion rate, preoperative and peak postoperative creatinine, time spent in intensive care unit and hospital, incidence of death, and postoperative need for hemodialysis. Principal findings include an increased rate of transfusion in the normal CVP group but increased rates of postoperative renal failure (elevated creatinine and more frequent need for dialysis) and 30-day mortality in the low CVP group. Conclusions: Despite success in lowering blood transfusion requirements in liver resection patients, a low CVP should be avoided in patients undergoing liver transplantation.