Abstract
BackgroundAscites is a major complication of decompensated liver cirrhosis. Intraabdominal hypertension and structural alterations of parenchyma involve decisive changes in hepatosplanchnic blood flow. Clearance of indo-cyanine green (ICG) is mainly dependent on hepatic perfusion and hepatocellular function. As a consequence, plasma disappearance rate of ICG (ICG-PDR) is rated as a useful dynamic parameter of liver function. This study primarily evaluates the impact of large-volume paracentesis (LVP) on ICG-PDR in critically ill patients with decompensated cirrhosis. Additionally, it describes influences on intraabdominal pressure (IAP), abdominal perfusion pressure (APP), hepatic blood flow, hemodynamic and respiratory function.MethodsWe analyzed LVP in 22 patients with decompensated liver cirrhosis. ICG-PDR was assessed by using noninvasive LiMON technology (Pulsion® Medical Systems; Maquet Getinge Group), and hepatic blood flow was analyzed by color-coded duplex sonography.ResultsParacentesis of a median volume of 3450 mL ascites evoked significant increases of ICG-PDR from 3.6 (2.8–4.6) to 5.1 (3.9–6.2)%/min (p < 0.001). Concomitantly, we observed a raise in “ICG-Clearance” from 99 (73.5–124.5) to 104 (91–143.5) mL/min/m2 (p = 0.005), while circulating blood volume index was unchanged [2412 (1983–3025) before paracentesis vs. 2409 (1997–2805) mL/m2, p = 0.734]. Sonography revealed a significant impact of paracentesis on hepatic blood flow: Hepatic artery resistance index dropped from 0.74 (0.68–0.75) to 0.68 (0.65–0.71) (p < 0.001) and maximum flow velocity in hepatic vein increased from 24 (17–30) to 30 (22–36) cm/s (p < 0.001). Consistent with previous studies, paracentesis caused significant decreases in IAP from 19.0 (15.0–20.3) to 11.0 (8.8–12.3) mmHg (p < 0.001) and central venous pressure from 22.5 (17.8–29.0) to 17.5 (12.8–24.0) mmHg (p < 0.001) with inverse increases in APP from 63.0 (56.8–69.5) to 71.0 (65.5–78.5) mmHg (p < 0.001). Changes in ICG-PDR were concomitant with changes in IAP (r = − 0.602) and APP (r = 0.576). Moreover, we found a substantial improvement in respiratory function. By contrast, hemodynamic parameters assessed by transpulmonary thermodilution, serum bilirubin and international normalized ratio did not change after paracentesis.ConclusionCritically ill patients with decompensated cirrhosis and elevated IAP showed dramatically impaired ICG-PDR. Paracentesis evoked an improvement in ICG-PDR in parallel with a decreased IAP and an increased APP, while conventional parameters of liver function did not change. This effect on ICG-PDR is mainly referable to a relief of intraabdominal hypertension and changes in hepatosplanchnic blood flow.
Highlights
Ascites is a major complication of decompensated liver cirrhosis
Between April 2016 and July 2017, a total of 29 critically ill patients with decompensated liver cirrhosis on our university hospital general intensive care unit (ICU) were screened for the feasibility of large-volume paracentesis (LVP), analyses of indocyanine green (ICG)-Plasma disappearance rate (PDR), intraabdominal pressure (IAP) and hemodynamic monitoring via transpulmonary thermodilution
acute and physiology chronic health evalu‐ ation (APACHE), sequential organ failure assessment (SOFA), model of end-stage liver disease (MELD)- and Child– Pugh scores are explainable by advanced hepatic impairment and critical illness
Summary
Ascites is a major complication of decompensated liver cirrhosis. Intraabdominal hypertension and structural alterations of parenchyma involve decisive changes in hepatosplanchnic blood flow. This study primarily evaluates the impact of large-volume paracentesis (LVP) on ICG-PDR in critically ill patients with decompensated cirrhosis. It describes influences on intraabdominal pressure (IAP), abdominal perfusion pressure (APP), hepatic blood flow, hemodynamic and respiratory function. Advanced cirrhosis is accompanied by structural alterations leading to increased intrahepatic vascular resistance [11, 12]. Cirrhosis provokes impairment of blood flow in hepatic veins as well as increases in hepatic artery resistance index [14, 15]. Color-coded duplex sonography provides a subjective, but noninvasive diagnostic approach regarding vascular disorders in advanced liver disease [16]
Sign-in/Register to view highlights & summary 
Published Version (
Free)
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call