Low Central Venous Pressure Research Articles

P737Fontan patients with fenestration acquire low central-venous pressure but hold poor cardiac performances

P737Fontan patients with fenestration acquire low central-venous pressure but hold poor cardiac performances

Hemostatic Complications in Hepatobiliary Surgery.

AbstractHepatobiliary surgery is a well-known risk factor for thrombotic complications but is also associated with substantial perioperative blood loss. Given the central role of the liver in hemostasis, hepatobiliary surgery is frequently accompanied by complex changes in the hemostatic system. Increasing knowledge of these changes has resulted in an improved understanding of the etiology of some of the hemostatic complications. In the early postoperative period a prolongation of conventional coagulation test times, such as the prothrombin time, is frequently seen. Together with a decreased platelet count, this suggests a hypocoagulable state. The concomitant decline of anticoagulant factors and development of a von Willebrand factor/ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13) imbalance, however, suggest a hypercoagulable state, potentially contributing to the risk of thromboembolism. Postoperative thromboprophylaxis should be initiated early to avoid thrombosis, and intensified prophylaxis might benefit high-risk patients. The risk of hemorrhagic complications during hepatobiliary surgery has diminished over time, mainly due to improved surgical and anesthesiological techniques. However, bleeding can still be profound in individual patients and is difficult to predict using (global) hemostasis tests. A restrictive transfusion and fluid infusion policy to maintain a low central venous pressure is crucial in prevention of perioperative bleeding. However, when active bleeding occurs, proactive prohemostatic management is required.

Should Low Central Venous Pressure Be Maintained during Liver Transplantation?

Low central venous pressure, which indirectly reflects free hepatic venous pressure, is maintained during hepatic resection surgery to reduce intraoperative blood loss by facilitating hepatic venous outflow. However, whether the low central venous pressure protocol established for non-transplant hepatobiliary surgery should be generalized to liver transplantation is controversial because patients with cirrhosis have decreased portal and hepatic venous blood flow and vulnerability to renal failure. However, consistent with observations from hepatic resection surgeries, lowering central venous pressure during the preanhepatic phase significantly reduces blood loss and transfusion volume. Conversely, inherent study limitations and different study designs have yielded different results in terms of renal dysfunction. Although hepatic venous outflow promoted by lowering blood volume seems to facilitate a liver graft to accommodate portal blood flow increased by portal hypertension-induced splanchnic vasodilatation, the association between low central venous pressure and reduced incidence of portal hyperperfusion injury has not been demonstrated. Stroke volume variation predicts fluid responsiveness better than central venous pressure, but it has not been associated with a greater clinical benefit than central venous pressure to date. Therefore, the safety of maintaining low central venous pressure during liver transplantation has not been verified, and further randomized controlled studies are warranted to establish a fluid management protocol for each phase of liver transplantation to reduce intraoperative blood loss and transfusion rate, thereby maintaining liver graft viability. In conclusion, low central venous pressure reduces intraoperative blood loss but does not guarantee renoprotection or graft protection.

Elevated Mean Airway Pressure and Central Venous Pressure in the First Day of Mechanical Ventilation Indicated Poor Outcome.

The relationship between respiratory mechanical parameters and hemodynamic variables remains unclear. This study was performed to determine whether mean airway pressure and central venous pressure in the first day of mechanical ventilation are associated with patient outcomes. Retrospective first 24-hour comparison during ICU stay. The Department of Critical Care Medicine of Peking Union Medical College Hospital. Patients with mechanical ventilation. None. The clinical data of patients who received mechanical ventilation, especially respiratory and hemodynamic data, were collected and analyzed. In terms of the hemodynamic and perfusion data, the nonsurvivors group (177/2,208) had higher heart rate, respiratory rate, central venous pressure, and lactates and a lower perfusion index and P(v-a)CO2 (p < 0.05). In terms of respiratory condition, mean airway pressure, peak airway pressure, positive end-expiratory pressure, driving pressure, and inspiratory time/total respiration time of nonsurvivors were significantly higher, and arterial oxygen pressure and dynamic compliance worsened and were lower than the survivors (p < 0.05). Increased central venous pressure (odds ratio, 1.125; 95% CI, 1.069-1.184; p < 0.001) and elevated mean airway pressure (odds ratio, 1.125; 95% CI, 1.069-1.184; p < 0.001) were independently associated with 28-day mortality. The area under receiver operating characteristic demonstrated that central venous pressure and mean airway pressure were measured at 0.795 (95% CI, 0.654-0.757) and 0.833 (95% CI, 0.608-0.699), respectively. Based on the cutoff of central venous pressure and mean airway pressure, all of the participants were divided into the following groups: low central venous pressure and mean airway pressure, only high central venous pressure or mean airway pressure, or high central venous pressure and mean airway pressure. Post hoc tests showed significant differences among these three groups based on 28-day survival (log rank [Mantel-Cox], 131.931; p < 0.001). During the first 24 hours of mechanical ventilation, patients with elevated mean airway pressure and elevated central venous pressure had worse outcomes.

Impact of the location of the fenestration on Fontan circulation haemodynamics: a three-dimensional, computational model study.

There is no consensus or theoretical explanation regarding the optimal location for the fenestration during the Fontan operation. We investigated the impact of the location of the fenestration on Fontan haemodynamics using a three-dimensional Fontan model in various physiological conditions. A three-dimensional Fontan model was constructed on the basis of CT images, and a 4-mm-diameter fenestration was located between the extracardiac Fontan conduit and the right atrium at three positions: superior, middle, and inferior part of the conduit. Haemodynamics in the Fontan route were analysed using a three-dimensional computational fluid dynamic model in realistic physiological conditions, which were predicted using a lumped parameter model of the cardiovascular system. The respiratory effect of the caval flow was taken into account. The flow rate through the fenestration, the effect of lowering the central venous pressure, and wall shear stress in the Fontan circuit were evaluated under central venous pressures of 10, 15, and 20 mmHg. The pulse power index and pulsatile energy loss index were calculated as energy loss indices. Under all central venous pressures, the middle-part fenestration demonstrated the most significant effect on enhancing the flow rate through the fenestration while lowering the central venous pressure. The middle-part fenestration produced the highest time-averaged wall shear stress, pressure pulse index, and pulsatile energy loss index. Despite slightly elevated energy loss, the middle-part fenestration most significantly increased cardiac output and lowered central venous pressure under respiration in the Fontan circulation.

Comparison Between 2 Strategies of Fluid Management on Blood Loss and Transfusion Requirements During Liver Transplantation

To compare the effects of low central venous pressure (LCVP) and transesophageal Doppler (TED)-guided fluid management on blood loss and blood transfusion during liver transplantation (LTx). Retrospective study. Single institution, university hospital. Adult recipients of LTx. Two groups: control (LCVP G), n=45 with CVP maintained 40% lower than the preoperative value during the preanhepatic phase. The mean arterial pressure was kept >60 mmHg. This group was matched with the second group (TED G); n = 45, in which a TED protocol was followed maintaining the systemic vascular resistance (SVR) more than 750 dynes•s•cm-5. Coagulation defects were corrected following thromboelastometry. Intraoperative blood loss, blood products, perioperative creatinine, lactate, and postoperative patients' stratification according to the Acute Kidney Injury Network classification were compared. Prior to the anhepatic phase, CVP was significantly lower in LCVP G (p < 0.001). TED G tended to have less but nonsignificant, blood loss, packed red blood cells, fresh frozen plasma, and platelets and received significantly less colloid and higher norepinephrine. Lactate was significantly higher in LCVP G at the end of the anhepatic phase and end of surgery while urine output in the preanhepatic phase was significantly lower. Creatinine was significantly lower on postoperative days 1 and 3, and Acute Kidney Injury Network stages were better on postoperative day 1 in TED G. During LTx, TED-guided fluid management, with norepinephrine used to maintain SVR, was similar to LCVP regarding blood loss and transfusion requirements and had better impacts on kidney function and lactate.

Benefits of ultra-fast-track anesthesia in left ventricular assist device implantation: a retrospective, propensity score matched cohort study of a four-year single center experience

BackgroundThe use of left ventricular assist devices (LVADs) has gained significant importance for treatment of end-stage heart failure. Fast-track procedures are well established in cardiac surgery, whereas knowledge of their benefits after LVAD implantation is sparse. We hypothesized that ultra-fast-track anesthesia (UFTA) with in-theater extubation or at a maximum of 4 h. after surgery is feasible in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level 3 and 4 patients and might prevent postoperative complications.MethodsFrom March, 2010 to March, 2012, 53 LVADs (50 Heart Mate II and 3 Heart Ware) were implanted in patients in our department. UFTA was successfully performed (LVADultra) in 13 patients. After propensity score matching, we compared the LVADultra group with a matched group (LVADmatch) receiving conventional anesthesia management.ResultsPatients in the LVADultra group had significantly lower incidences of pneumonia (p = 0.031), delirium (p = 0.031) and right ventricular failure (RVF) (p = 0.031). They showed a significantly higher cardiac index in the first 12 h. (p = 0.017); a significantly lower central venous pressure during the first 24 h. postoperatively (p = 0.005) and a significantly shorter intensive care unit (ICU) stay (p = 0.016). Kaplan-Meier analysis after four years of follow-up showed no significant difference in survival.ConclusionIn this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in LVAD implantation in selected patients with INTERMACS level 3–4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective randomized investigations should examine the preservation of right ventricular function in larger numbers and identify appropriate selection criteria.

Partial clamping of the infrahepatic inferior vena cava for blood loss reduction during anatomic liver resection: A prospective, randomized, controlled trial

Anatomic liver resection often requires the exposure of the hepatic vein on its cut surface, and theoretically, lower central venous pressure aids in reducing blood loss. Therefore, we hypothesized that manipulating the central venous pressure by partially clamping the infrahepatic inferior vena cava might reduce blood loss during anatomic liver resection. Patients undergoing planned anatomic liver resections were allocated randomly to the partial infrahepatic inferior vena cava clamping or nonclamping groups. Hepatocellular carcinoma diagnosis was set as a stratifying factor because of underlying liver disease. The primary outcome was intraoperative blood loss. Secondary outcomes were intraoperative parameters and postoperative safety. We submitted the detailed protocol to the University Hospital Medical Information Network Clinical Trials Registry (Registration number: UMIN000007339 [http://www.umin.ac.jp.]). Between August 2011 and August 2015, 90 patients were allocated randomly. Both groups had comparable baseline characteristics. The central venous pressure was reduced from 6.0 to 3.0mm Hg in the partial inferior vena cava clamping group without any complications (P<.001). Among all eligible patients, median values for total blood loss, blood loss during liver resection, and blood loss per transected area (nonclamping vs clamping groups) were 360 vs 350mL(P=.19), 310 vs 250mL(P=.045), and 4.9 vs 3.6mL/cm2 (P=.15), respectively. However, among the subgroup of patients with hepatocellular carcinoma, these median values were 460 vs 290mL(P=.06), 365 vs 217mL(P=.007), and 5.2 vs 3.6mL/cm2 (P=.03), respectively. Morbidities and laboratory data were comparable in both groups. Partial infrahepatic inferior vena cava clamping safely reduced central venous pressure and may reduce blood loss in patients with hepatocellular carcinoma when central venous pressure is >5mm Hg at hepatic parenchymal transection.

The influence of PEEP and positioning on central venous pressure and venous hepatic hemodynamics in patients undergoing liver resection.

In order to assess the occurrence of blood congestion in the liver during liver resection, we aimed to evaluate the influence of a positive-end-expiratory-pressure (PEEP) and positioning of patients on central venous pressure (CVP) and venous hepatic blood flow parameters. We further analyzed correlations between CVP and venous hepatic blood flow parameters. In 20 patients scheduled for elective liver resection we measured CVP and quantified venous hepatic hemodynamics by ultrasound assessment of flow-velocity and diameter of the right hepatic vein and the portal vein after equilibration following these maneuvers: M1: 0° supine position, PEEP 0cmH2O; M2: 0° supine position, PEEP 10cmH2O; M3: 20° reverse-trendelenburg position; PEEP 10cmH2O; M4: 20° reverse-trendelenburg position, PEEP 0cmH2O. Changing from supine to reverse-trendelenburg position led to a significant decrease in CVP (M3 5.95 ± 2.06 vs. M1 7.35 ± 2.18mmHg and M2 8.55 ± 1.79mmHg). A PEEP of 10cmH2O and reverse-trendelenburg position led to significant reduction of systolic (VsHV) and diastolic (VdHV) flow-velocities of the right hepatic vein (VsHV M3 19.96 ± 6.47 vs. M1 27.81 ± 11.03cm s-1;VdHV M3 14.94 ± 6.22 vs. M1 20.15 ± 10.34cm s-1 and M2 20.19 ± 13.19cm s-1) whereas no significant changes of flow-velocity occurred in the portal vein. No correlations between CVP and diameters or flow-velocities of the right hepatic and the portal vein were found. Changes of central venous pressure due to changes of PEEP and positioning were not correlated with changes of venous hepatic blood flow parameters as measured after equilibration. Strategies aiming for low central venous pressure cannot be supported by these results. However, before ruling out low-CVP-strategies during liver resections these results should be confirmed by further studies.

Low Positive Airway Pressure without Positive End-Expiratory Pressure Decreases Blood Loss during Hepatectomy in Living Liver Donors

Background/Aims: Despite the development of strategies to minimize blood loss during hepatectomy challenges remain. Our aim was to determine whether low positive airway pressure (PAP) without positive end-expiratory pressure (PEEP) could minimize blood loss during hepatectomy. Methods: Forty-one living liver donors who underwent extended left lobectomy or right lobectomy between December 2012 and November 2013 were retrospectively analyzed. In the standard PAP group (n = 18), tidal volume was 8-10 ml/kg, respiratory rate was 10-12/min and PEEP was maintained at 5 cm H₂O. In the low PAP group (n = 23), tidal volume was reduced to 5 ml/kg, respiratory rate was increased to 15/min and PEEP maintained at 0 cm H₂O. Low central venous pressure (CVP) was maintained during surgery in all cases. Results: The low PAP group had significantly less blood loss (p = 0.0075) and shorter operation time (p = 0.0303) than the standard PAP group. In multiple regression analysis, ventilation mode and median CVP were found to be determining factors for blood loss. In no case did the ventilation mode affect perioperative management. Conclusions: Low PAP without PEEP is a safe mechanical ventilation mode that might help minimize blood loss along with CVP monitoring during hepatectomy.

Precise hepatectomy based on the optimized technique of hepatic blood flow occlusion combined with the curettage and cut technique by electrotome.

The aim of this study was to evaluate the outcome of precise hepatectomy based on the optimized technique of hepatic blood flow occlusion combined with the curettage and cut technique by electrotome. Hospitalized patients with primary liver cancer treated in our hospital were included in this study and all patients (N.=61) were numbered according to the inclusion sequence and were randomized into group A and group B: 1) group A: precise liver resection by using simplified blocking combining with electrotome; 2) group B: precise liver resection by using half-hepatic occlusion + CUSA assisting liver parenchyma transection+ lower central venous pressure controlled by the anesthesiologist. Postoperative laboratory examination data (blood routine, liver function, renal function, blood coagulation function, AFP quantitation) were collected, including WBC, alanine aminotransferase (ALT), total bilirubin (TBIL), prothrombin time (PT), creatinine (Cr), abdominal drainage volume, intra-abdominal hemorrhage, bile leakage, blood transfusion, time of postoperative passage of gas by anus, and length between postoperation and discharge. Five days postsurgery, the value of WBC between groups A and B were not significant different (8.9±2.2 vs. 8.3±2.8, P>0.05). The ALT, PT, Cr, abdominal drainage volume, abdominal drainage volume, intra-abdominal hemorrhage, bile leakage, blood transfusion, and time of postoperative passage of gas by anus between group A and B were not significant different postoperatively, respectively. And also, the length between postoperation and discharge were not significant different between two groups. Precise hepatectomy based on the optimized technique of hepatic blood flow occlusion combined with the curettage and cut technique by electrotome works well. This technology has a low requirement for hospital's operation condition and anesthetist, so it carries out a new route for the wide application of precise liver resection in basal hospitals.

Methods to decrease blood loss during liver resection: a network meta-analysis.

Methods to decrease blood loss during liver resection: a network meta-analysis.

Initial central venous pressure could be a prognostic marker for hemodynamic improvement of polymyxin B direct hemoperfusion: a retrospective cohort study.

BackgroundDirect hemoperfusion with polymyxin B-immobilized fiber column (PMX-DHP) could improve the hemodynamic status of septic shock patients. As PMX-DHP is an invasive and costly procedure, it is desirable to estimate the therapeutic effect before performing the therapy. However, it is still unclear when this therapy should be started and what type of sepsis it should be employed for. In this study, we retrospectively examined the clinical effect of patients treated with PMX-DHP by using central venous pressure (CVP).MethodsSeventy patients who received PMX-DHP for septic shock during the study period were recruited and divided into a low CVP group (n = 33, CVP < 12 mmHg) and a high CVP group (n = 37, CVP≧12 mmHg). The primary endpoint was vasopressor dependency index at 24 hours after starting PMX-DHP, and the secondary endpoint was the 28-day survival rate. Additionally, we performed a multivariate linear regression analysis on the difference in the vasopressor dependency index.ResultsThe vasopressor dependency index significantly improved at 24 h in the low CVP group (0.33 to 0.16 mmHg−1; p < 0.01) but not in the high CVP group (0.43 to 0.34 mmHg−1; p = 0.41), and there was a significant difference between the two groups in the index at 24 h (p = 0.02). The 28-day survival rate was higher in the low CVP group (79 vs. 43 %; p < 0.01). Multivariate linear regression analysis showed that CVP (p = 0.04) was independently associated with the difference in the vasopressor dependency index.ConclusionsOur study indicates that the clinical effect of PMX-DHP for septic shock patients with higher CVP (≧12 mmHg) might be limited and that the initial CVP when performing PMX-DHP could function as an independent prognostic marker for the hemodynamic improvement.Electronic supplementary materialThe online version of this article (doi:10.1186/s40560-016-0186-8) contains supplementary material, which is available to authorized users.

Application of controlled venous pressure in hepatectomy salvage liver transplantation versus primary liver transplantation in the treatment of hepatocellular carcinoma: a meta-analysis

Objective To investigate the effectiveness and safety of controlled venous pressure in liver surgery and further to compare the clinical outcomes of low central venous pressure (LCVP) by intraoperative anesthetic control (IAC). Methods Online databases including PubMed, Embase, Cochrane Library, Clinical trials.gov, and China biology medicine database were comprehensively searched. After identifying relevant studies out of the search results, quality assessment was performed according to the methods recommended by the Cochrane collaboration. A meta-analysis was performed by both direct comparison and indirect comparison. Results Thirteen studies containing 702 patients were included. Compared with control, controlled venous pressure significantly decreased liver transected time [weighted mean difference (WMD)=-5.84, 95% confidence interval (CI): -7.68, -4.00, P<0.01], total blood loss (WMD=-346.28, 95%CI: -431.21, -261.35, P<0.01], blood loss during transaction (WMD=-718.42, 95%CI: -1 279.18, -157.66, P<0.01], transfusion rate [odds ratio (OR)=0.25, 95%CI: 0.15, 0.42, P<0.01], and total incidence of complications. Further analysis of inferior vena cava clamping (IVCC) and IAC showed that there was no significant difference in aspects of main clinical outcomes. Conclusion LCVP during hepatectomy is easy to control, decreased liver transected time, total blood loss, blood loss during transection, transfusion rate, and total incidence of complications. It has no detrimental effect to hepatic or renal function, and is beneficial for more rapid recovery of patients. Key words: Liver resection; Low central venous pressure; Meta-analysis

Safety and feasibility of phlebotomy with controlled hypovolemia to minimize blood loss in liver resections

Liver resection can be associated with significant blood loss and transfusion. Whole blood phlebotomy is an under-reported technique, distinct from acute normovolemic hemodilution, the goal of which is to minimize blood loss in liver operation. This work sought to report on its safety and feasibility and to describe technical considerations. Consecutive patients who had an elective liver resection and concurrent phlebotomy between 2013 and 2016 were examined prospectively. Formal Inclusion and exclusion criteria were defined a priori. All surgical indications were allowed. All procedures were carried out with a stated goal of low central venous pressure anesthesia (<5cmH2O). The target phlebotomy volume was 7-10mL/kg of patient body weight. The removed blood was not replaced by intravenous fluid. Removed blood was returned back to the patient after parenchymal transection. Safety end points were examined. A historic cohort (2010-2014) of major resections was included for comparison. A total of 37 patients underwent liver resection with phlebotomy (86% major) and 101 without. Half had metastatic colorectal cancer. The median phlebotomy volume was 7.2mg/kg (4.7-10.2), yielding a median drop in central venous pressure of 3cmH2O (0-15). Median blood loss was 400 vs 700mL(P=.0016), and the perioperative transfusion rate was 8.1% vs 32% (P=.0048). There was no difference between the 2 groups in overall complications, mortality, intensive care admission, duration of stay, or end-organ ischemic complications. Whole blood phlebotomy with controlled hypovolemia prior to liver resection seems to be safe and feasible. Comparative studies are required to determine its effectiveness.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations.

Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Cirugía hepática: algunas consideraciones más allá de la técnica quirúrgica

The mortality of liver resection surgery is 1-2%. Improve this will require optimizing details involving all caregivers of these patients. The first of these points is the evaluation of postoperative liver function. Various methods have been used to estimate it, without conclusive results regarding what is the most appropriate. Several studies evaluating the amount of residual parenchyma and its relationship to the development of postoperative liver failure recommend that in the presence of a healthy liver should be 20-25% of liver volume, 30-60% in cases of conditions that impair the functionality and 40-70% in cases of cirrhosis. The contribution of fluids administration and its relationship with morbidity, bleeding and development of renal failure have been studied. The volume restriction, maintenance of low central venous pressures appear as recommended strategies but must not compromise systemic perfusion that can determine organ dysfunction. Unlike what was observed in critically ill patients, the use of starches appears as a safe alternative in healthy patients and those undergoing liver transplantation. Alterations in coagulation tests should be evaluated, ideally through methods that allow to identify the cause. The thromboelastography appears as a suitable alternative. Prophylactic administration of blood components is not indicated and can be a source of morbidity. Analgesia should be optimized, being epidural analgesia a good alternative in the presence of healthy liver and procedures involving no more than a lobectomy.

The significance of underlying cardiac comorbidity on major adverse cardiac events after major liver resection

BackgroundThe risk of postoperative adverse events in patients with underlying cardiac disease undergoing major hepatectomy remains poorly characterized. MethodsThe NSQIP database was used to identify patients undergoing hemihepatectomy and trisectionectomy. Patient characteristics and postoperative outcomes were evaluated. ResultsFrom 2005 to 2012, 5227 patients underwent major hepatectomy. Of those, 289 (5.5%) had prior major cardiac disease: 5.6% angina, 3.1% congestive heart failure, 1% myocardial infarction, 54% percutaneous coronary intervention, and 46% cardiac surgery. Thirty-day mortality was higher in patients with cardiac comorbidity (6.9% vs. 3.7%, P = 0.008), including the incidence of postoperative cardiac arrest requiring cardiopulmonary resuscitation (3.8% vs. 1.2%, P = 0.001) and myocardial infarction (1.7% vs. 0.4%, P = 0.011). Multivariate analysis revealed that functional impairment, older age, and malnutrition, but not cardiac comorbidity, were significant predictors of 30-day mortality. However, prior percutaneous coronary intervention was independently associated with postoperative cardiac arrest (OR 2.999, P = 0.008). ConclusionWhile cardiac comorbidity is not a predictor of mortality after major hepatectomy, prior percutaneous coronary intervention is independently associated with postoperative cardiac arrest. Careful patient selection and preoperative optimization is fundamental in patients with prior percutaneous coronary intervention being considered for major hepatectomy as restrictive fluid management and low central venous pressure anesthesia may not be tolerated well by all patients.

Global myocardial oedema in advanced decompensated heart failure.

To use cardiac magnetic resonance (CMR) imaging with quantitative T2 mapping as surrogate for myocardial water content in patients with advanced decompensated heart failure (ADHF), compare these values with T2-values observed in chronic heart failure, and evaluate the change with decongestive therapy. Volumetric CMR measurements and quantitative T2 mapping were performed in 18 consecutive ADHF patients with clinical signs of volume overload. Eleven patients with stable heart failure were used as controls. Vasodilator therapy and diuretics were administered to achieve a pulmonary arterial wedge pressure (PAWP) of <18 mmHg and central venous pressure (CVP) of <12 mmHg, after which CMR was repeated. ADHF patients (62 ± 12 years; 89% male; left ventricular ejection fraction 23 ± 8%) presented with low cardiac index (2.08 ± 0.59 L/min/m2), high PAWP (25 ± 7 mmHg), and high CVP (14 ± 5 mmHg). After decongestion, the patients had a significant increase in cardiac index (+0.41 ± 0.53 L/min/m2; P = 0.005) and decreases in both PAWP (-9 ± 6 mmHg; P < 0.001) and CVP (-6 ± 5 mmHg; P < 0.001). At baseline, global left ventricular T2-values were higher in ADHF patients compared with controls (59.5 ± 4.6 vs. 54.7 ± 2.2 ms, respectively; P = 0.001). After decongestion, T2-values fell significantly to 55.9 ± 5.1 ms (P = 0.001), comparable with controls (P = 0.580). In contrast, psoas muscle T2-values were similar at baseline (38.6 ± 4.4 ms) vs. after decongestion (37.8 ± 4.8 ms; P = 0.397). Each 1 ms decrease in global left ventricular T2-value during decongestion was associated with a 1.14 ± 0.40 mmHg decrease in PAWP (P = 0.013), after correction for age and gender. Patients presenting with ADHF and volume overload have increased global left ventricular-but not psoas muscle-T2-values, which decrease with successful decongestion. Relief of myocardial oedema correlates with haemodynamic unloading.

Central venous pressure as an adjunct to flow-guided volume optimisation after induction of general anaesthesia.

Although the central venous pressure (CVP) is often used as a guide to volume status in major surgery and intensive care, fluid therapy should be guided by the response of the stroke volume (SV) to a fluid bolus. The present study evaluates whether the central venous pressure (CVP) can serve as an adjunct to decisions of whether or not fluid should be infused. Stroke volume (SV) and stroke volume variation (SVV) was monitored with FloTrac/Vigileo and the CVP were measured in 80 patients just before general anaesthesia was induced (baseline) and then, before each of three successive bolus infusions of 3 mL kg⁻¹ of 6% hydroxyethyl starch 130/0.4. A patient showed fluid responsiveness and was denoted a "responder" if SV increased by ≥10% from the bolus infusion. The CVP was higher in non-responders (mean 7.2 mm Hg) than in responders (mean 5.8 mm Hg, P < 0.0001). In non-responders but not in responders, the absence or presence of a rise in CVP improved the prediction of whether the patient would show fluid responsiveness during the next fluid bolus. For example, if no rise in CVP occurred the chance was 48% of subsequent fluid responsiveness, while this chance was only 9% for those who had an increase in CVP (P < 0.004). There was only a fair concordance between fluid responsiveness as indicated by SV and SVV (Cohen´s kappa 0.28). A low CVP suggests that the patient is lower on the Frank-Starling curve than indicated by SV as measured by FloTrac/Vigileo.