Abstract
Background: Monitoring of adequacy of sedation and careful drug selection can minimize the risks of over sedation and side effects. We evaluate the safety and efficiency of patient state index (PSI) versus Ramsay sedation scale (RSS) on postoperative sedation for living donor liver transplantation (LDLT) recipients. Methods: Sixty postoperative mechanically ventilated LDLT recipients sedated with desflurane were randomly allocated to either R group (Ramsay group n=30), where sedation assessed using clinical assessment with the RSS, or S group (SEDline group n=30) where sedation assessed with PSI to target sedation depth (50-75). Memorization of five words, Trieger's dot (TT), digit symbol substitution tests (DSST) were recorded. Transesophageal Doppler (TED) parameters were recorded. Duration of mechanical ventilation, postoperative side effects and cost, were recorded. Results: Mean values of time from cessation of desflurane to eye opening (min), hand squeezing (min), verbal command (min) and to extubation were statistically significant, shorter in S group than R group (p<0.001). Five words recall, TT and DSST were better in S group. Patients required norepinephrine were lower in S group than R group (10 (33.3%) vs. 23 (76.7%) P=0.001). Duration of ventilation was shorter in S group than R group (6.83 ± 2.00 vs. 8.26 ± 1.68 hour, P=0.004). Systemic vascular resistance (SVR) and mean blood pressure (MBP) were better preserved in S compared to R group at all measuring points (SVR, MBP after 2hrs sedation 915.73 ± 194.31 vs. 669.20 ± 119.82 dyn.sec.cm-5, P<0.001 and 78.03 ± 6.242 vs. 65.13 ± 67.58 mmHg, P<0.001, respectively). Postoperative drowsiness, nausea and vomiting were lower in S compared to R group (P=0.000). Conclusion: Sedation guided with PSI preserved better haemodynamics, enhanced recovery and rapid ventilation weaning at a lower cost compared to RSS monitoring. PSI-augmented sedation monitoring markedly reduced the total dose of sedative used to achieve the same level of clinical sedation without any measurable adverse effects.
Highlights
Intensive care management of recipients of liver transplantation mainly centers on rapid haemodynamic stabilization, correction of coagulopathy, early weaning from mechanical ventilation, proper fluid administration, kidney function preservation, graft rejection prevention, and infection prophylaxis [1]
The number of patients who presented with drowsiness were significantly lower in S group (n=0) (0.0%) than R group (n=5) (16.7%), P value>0.001 associated with lower number of patients who complained of nausea and vomiting (n=0) (0.0%) vs. (n=6) (20%) in S than R group respectively, P value>0.001
The use of transoesophageal Doppler (TED) was able to demonstrate significant hemodynamic differences between both groups during the study period where mean blood pressure (MBP) and systemic vascular resistance (SVR) were significantly lower in R group compared to S group, the need for noradrenaline support was significantly lower in S group and this again could be attributed to the minimal amount of sedative used to maintain an adequate level of sedation in S group
Summary
Intensive care management of recipients of liver transplantation mainly centers on rapid haemodynamic stabilization, correction of coagulopathy, early weaning from mechanical ventilation, proper fluid administration, kidney function preservation, graft rejection prevention, and infection prophylaxis [1]. A considerable number of liver transplant recipients will require mechanical ventilation during their immediate postoperative care for which they will receive one or more sedative medications. The primary hurdle for brain function monitoring in a light to moderate sedation procedure has been electromyographical (EMG) interference from the frontalis muscle immediately beneath the array electrodes. This very high frequency and low voltage signal can cause an artificially high score on the patient state index (PSI). This study aims to evaluate PSI monitoring and whether it provides additional value to traditional observational assessment in selecting an ideal level of patient sedation for postoperative mechanically ventilated ALDL recipients in the ICU setting using desflurane sedation. We evaluate the safety and efficiency of patient state index (PSI) versus Ramsay sedation scale (RSS) on postoperative sedation for living donor liver transplantation (LDLT) recipients
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