Low Central Venous Pressure Research Articles

Intention to control low central venous pressure reduced blood loss during laparoscopic hepatectomy: A double-blind randomized clinical trial

BackgroundExcessive intraoperative hemorrhage is a critical factor of poor prognoses after hepatectomy. Low central venous pressure during parenchymal transection is recognized to effectively reduce intraoperative hemorrhage in open procedures. However, the role of controlled low central venous pressure in laparoscopic hepatectomy is still controversial. MethodsIn the present randomized clinical trial, we set up a standard boundary of low central venous pressure according to our Pilot Study, then enrolled patients scheduled for elective laparoscopic hepatectomy and allocated them randomly to a group undergoing central venous pressure reduction by anesthesiologic interventions or a control group. The primary efficacy endpoint was total intraoperative blood loss and perioperative adverse events. Analyses were performed following the intention-to-treat principle, and patients and surgeons were blinded (ClinicalTrials.gov, Number: NCT03422913). ResultsBetween January 2017 and October 2018, 146 out of 469 patients were randomized and eligible for inclusion in the final analyses. Based on the retrospective training cohort, we set a central venous pressure of 5 cm H2O as a cutoff value (standard low central venous pressure). Compared with patients in the control group, those in the controlled low central venous pressure group had a significantly lower central venous pressure during resection (4.83 ± 3.41 cm H2O vs 9.26 ± 3.38 cm H2O; P < .001) and significantly reduced total intraoperative blood loss (188.00 ± 162.00 mL vs 346.00 ± 336.00 mL; P < .001). The perioperative adverse events were comparable in both study groups (P = .313). ConclusionThe safety and efficacy of controlled low central venous pressure were demonstrated in complex laparoscopic hepatectomy for the first time by our study, and this technique is recommended to be applied routinely in laparoscopic hepatectomy.

The effect of low central venous pressure on hepatic surgical field bleeding and serum lactate in patients undergoing partial hepatectomy: a prospective randomized controlled trial

BackgroundThis prospective randomized controlled study was designed to evaluate the effect of fluid restriction alone versus fluid restriction + low central venous pressure (CVP) on hepatic surgical field bleeding, intraoperative blood loss, and the serum lactate concentration in patients undergoing partial hepatectomy.MethodsOne hundred forty patients undergoing partial hepatectomy with intraoperative portal triad clamping were randomized into a fluid restriction group (Group F) or fluid restriction + low CVP group (Group L). Both groups received limited fluid infusion before the liver lesions were removed. Ephedrine was administered if the systolic blood pressure (SBP) decreased to <90 mmHg for 1 min. When the urine output was <20 ml/h or the SBP was <90 mmHg for 1 min more than three times, an additional 200 ml of crystalline solution was quickly infused within 10 min. In addition to fluid restriction, patients in Group L received continuous nitroglycerin and esmolol infusion to maintain a low CVP. The duration of portal triad clamping, frequency of additional fluid infusion, frequency of ephedrine administration, intraoperative blood loss, extent of liver resection, and bleeding score of the hepatic surgical field were recorded. Arterial blood gas analysis was performed before anesthesia (T1), after liver dissection and immediately before liver resection (T2), 10 min after removal of the liver lesion (T3), and before the patient was discharged from the postanesthesia care unit (T4).ResultsBeing in the fluid restriction Group (Group F) (odds ratio = 5.04) and cirrhosis (odds ratio = 3.28) were risk factors for hepatic surgical field bleeding. Factors contributing to intraoperative blood loss were the operation time, duration of portal triad clamping, and extent of resection. No significant between-group difference was observed for blood loss or blood transfusion. The serum lactate concentration peaked at T3 in both groups.ConclusionsMaintaining a lower CVP during hepatectomy provides an optimal surgical field but has no significant effect on intraoperative blood loss. Moreover, lower CVP does not increase the serum lactate concentration.Trial registration“A comparative study of the effect fluid restriction and low CVP pressure on the oozing of blood in liver wounds and blood lactate in patients undergoing partial hepatectomy” was prospectively registered as a trial (registration number: ChiCTR-INR-17014172, date of registration: 27 December 2017).

Goal-directed fluid therapy versus low central venous pressure strategy during major liver resections (GALILEO): A patient- and surgeon-blinded randomized controlled trial

Background: A recent worldwide survey confirmed that low central venous pressure (Low-CVP) is the current clinical standard during major liver resections, aimed at reducing blood loss and optimal quality of the surgical field. In recent years, however, goal-directed fluid therapy (GDFT) has shown to reduce postoperative morbidity in many types of high-risk abdominal surgery, but evidence in major liver resections is scarce. The aim of this study was to assess the effectiveness of GDFT compared to Low-CVP during major liver resection. Methods: This was a randomized controlled, patient- and surgeon-blinded, single-center trial. Patients undergoing major liver resection were randomized to receive either GDFT or Low-CVP. Patients who were found to have non-resectable disease during exploration were replaced (modified intention-to-treat). Primary outcome was intraoperative blood loss. Secondary outcomes included major complications (= grade 3 Clavien-Dindo) and quality of the surgical field (scale 0[worst]-100[best]). Results: Overall, 52 patients were randomized of whom 12 did not undergo resection (6 in each group), leaving 40 patients who underwent major liver resection (GDFT n=20, Low-CVP n=20). CVP during transection of the liver parenchyma was significantly lower with the use of Low-CVP (7(SD3) versus 3(SD2) mmHg, P<0.001). No significant differences were seen regarding blood loss (for GDFT 1275ml [IQR:760-1740] versus 1425ml for Low-CVP [IQR:850-1950], P=0.635) or major complications (40% [GDFT] versus 55% [Low-CVP], P=0.342). Liver surgeons were not able to identify which strategy was used (correct in 41% [GDFT] and 70% [Low-CVP], kappa=0.05 indicating poor association). Quality of the surgical field did not differ between groups: 80 [IQR:65-87] versus 80 [IQR:70-85], p=0.961. Conclusion: In this randomized patient- and surgeon-blinded trial in major liver resections, intraoperative blood loss, major morbidity, and quality of the surgical field did not differ between GDFT and Low-CVP. These findings suggest that GDFT can safely be used in major liver resections.

Relation between central venous pressure values and outcome in critically ill patients

Background Central venous pressure (CVP) was the most commonly used parameter to guide fluid responsiveness. However, recent studies showed that there is no correlation between CVP and circulating blood volume, and CVP more than 8 mmHg is independently associated with a higher mortality and increased risk of acute kidney injury in patients with sepsis and heart failure. Objective The aim of this study was to assess the effect of CVP over 7 days after ICU admission on clinical prognosis and mortality. Patients and methods The study was conducted on 218 patients in whom hemodynamic monitoring was required, and CVP was measured from the first day of ICU admission. Three values of CVP were selected to be measured (the values once inserted, the peak values, and the mean values of CVP) throughout the monitoring process over 7 days of ICU admission. Acute Physiology and Chronic Health Evaluation II score was calculated on admission, and Sequential Organ Failure Assessment (SOFA) score was calculated every other day. Length of ICU stay, mechanical ventilation days, and mortality at days 7 and 28 were recorded. Results Although the initial CVP values were only correlated with mean of SOFA scores, mean and peak CVP values were correlated with Acute Physiology and Chronic Health Evaluation II score, mean SOFA score, mechanical ventilation days, and mortality. Only peak CVP showed correlation with mean creatinine, and only mean CVP values were correlated with length of ICU stay. According to mean CVP values, patients were classified as low CVP ( 12 mmHg). The elevated mean CVP group was associated with increased 28-day mortality, and regarding further investigations such as renal function, duration of mechanical ventilation, and laboratory results related to organ dysfunction, it also demonstrated that higher mean CVP group was associated with poor ICU outcome for patients in ICU settings. Conclusion The study showed that for patients in ICU settings, elevated mean CVP load was associated with poor clinical outcome and prolonged treatment in ICU. Level and duration of elevated mean CVP should be evaluated, and more effort should be made to establish the cause and appropriate treatment for elevated mean CVP.

Ultrasonographic measurement of inferior vena cava collapsibility index and its correlation to central venous pressure in adult critically ill patients

Background Central venous pressure (CVP) is currently one of the most widely used parameters for the determination of volume status in critically ill patients. To measure CVP, a central venous catheter must be inserted. This process is invasive, requires complex training, and has many complications such as bleeding, traumatic pneumothorax, and infection. Also it may be contraindicated in the presence of coagulation abnormalities which are not a rare finding in critically ill patients. Transabdominal ultrasonographic determination of inferior vena cava (IVC) collapsibility index (CI) can provide a rapid, noninvasive, easy, and reproducible method of determination of volume status in critically ill patients, which avoids the risk and complications of invasive central venous catheterization. Patients and methods The prospective study was carried out in Zagazig University Hospital. A total of 86 patients who were admitted to trauma and surgical emergency ICU at Zagazig University Hospitals were eligible for enrollment in this study over the period of 2 years (October 2015–October 2017). Each patient had simultaneous measurement of CVP and IVC-CI on four different sessions; the first was on admission, the second was 6 h after admission, the third was 12 h after admission, and the fourth was 24 h after admission. The patient sample was divided into two subgroups based on the mode of ventilation and CVP value to compare the strength of correlation between caval index and CVP value in the two groups. Results Our study showed that IVC-CI has significant negative correlation with CVP value (r=−85, P˂0.001 at 95% confidence interval) and it is better correlated with mean arterial blood pressure and lactate clearance as compared with CVP. However, it correlated better in spontaneously breathing patients (r=−0.86, P˂0.001) than in mechanically ventilated patients (r=−0.84, P˂0.001). IVC-CI has shown to correlate better with CVP value in lower values (˂10 cmH2O) (r=−0.8, P˂0.001) than in higher values (≥10 cmH2O) (r=−0.6, P˂0.001). We also concluded an IVC-CI cutoff value of 29% to discriminate between CVP values less than 10 cmH2O and values more than or equal to 10 cmH2O with high sensitivity (88.6%) and specificity (80.4%). Conclusion IVC-CI has a strong inverse relationship with CVP which is more pronounced at low CVP values. Point-of-care ultrasonographically measured IVC-CI is very likely to be a good alternative to CVP measurement with a high degree of precision and reproducibility

Central venous pressure and the risk of diuretic-associated acute kidney injury in patients after cardiac surgery

When prescribing diuretics in the postcardiac surgical intensive care unit (ICU), clinicians may use central venous pressure (CVP) to assess volume status and the risk of acute kidney injury (AKI). In this study, we examined how the risk of diuretic-associated AKI varied with CVP in patients undergoing cardiac surgery. We used the Medical Information Mart for Intensive Care database to study adults admitted to the postcardiac surgical ICU at an urban, academic medical center between 2001 and 2012. We examined the odds of AKI per 1-mm Hg increase in CVP among patients receiving intravenous loop diuretics using multivariable adjusted logistic regression. We examined the risk of AKI among patients with diuretic use (vs nonuse) across tertiles of CVP using inverse probability treatment weighting. Among 4,164 patients receiving intravenous loop diuretics, the adjusted odds of subsequent AKI were 1.11 (95% CI 1.08-1.13) times higher per mm Hg increase in mean CVP. This association was log-linear across the entire range of CVPs observed. In the analysis of diuretic use (n = 5,396), the adjusted risk ratio for AKI with diuretic use (vs nonuse) was 1.33 (95% CI 1.21-1.47) and did not materially differ across tertile of CVP. Higher rather than lower CVP is an independent marker of AKI risk. The risk of AKI associated with diuretic use may not be influenced by CVP. Novel methods of assessing volume status and AKI risk are needed to guide patient selection for diuretic therapy.

Splanchnic and systemic circulation cross talks: Implications for hemodynamic management of liver transplant recipients.

The interaction between splanchnic and systemic circulation has many hemodynamic and renal consequences during liver transplant. In a patient with liver cirrhosis, splanchnic vasodilatation causes arterial steal from the systemic circulation into the splanchnic bed, which decreases the effective blood volume. Moreover, rapid volume loading in these patients has less impact on the cardiac output because a higher proportion of infused fluid is shifted to the splanchnic area. Thus, in dissection phase, the traditional approach of volume loading to maintain intraoperative hemodynamic stability not only seems ineffective, but it may also aggravate surgical bleeding. Two approaches of volume therapy have been mentioned to maintain hemodynamic stability during liver transplantation: splanchnic volume reduction by volume restriction with or without phlebotomy to maintain low central venous pressure (CVP), and splanchnic decongestion using splanchnic vasoconstrictors. After reperfusion, an increase in the central blood volume was thought to have a deleterious effect on the new graft function; however, the precise central venous pressure value that causes hepatic congestion after reperfusion is unknown.

Central Venous Pressure (CVP) Reduction Associated With Higher Cardiac Output (CO) Favors Good Prognosis of Circulatory Shock: A Single-Center, Retrospective Cohort Study.

Background: The Frank-Starling curve is the basis of hemodynamics. Changes in cardiac output (CO) caused by central venous pressure (CVP) are the most important concerns in the treatment of critically ill patients.Objectives: To explore the use of CVP and its relevant mechanisms with respect to CO in the clinic.Methods: A total of 134 patients with circulatory shock were retrospectively included and analyzed. Hemodynamic data were recorded and analyzed at PICCO initiation and 24 h after PICCO. Data regarding 28-day mortality and renal function were also collected.Results: The patients were divided into a CVP↑+ CO↑ group (n = 23), a CVP↑+ CO↓ group (n = 29), a CVP↓+ CO↑ group (n = 44), and a CVP↓+ CO↓ group (n = 38) based on values at PICCO initiation and 24 h after PICCO. Post- hoc tests showed that the CVP↓+ CO↑ group had a higher 28-day survival than the other groups [log-rank (Mantel-Cox) = 8.758, 95%, CI, 20.112–23.499, P = 0.033]. In terms of hemodynamic characteristics, the CVP↓+ CO↑ group had a lower cardiac function index (CFI) (4.1 ± 1.4/min) and higher extravascular lung water index (EVLWI) (11.0 ± 4.7 ml/kg) at PICCO initiation. This group used more cardiotonic drugs (77.3%, P < 0.001) and had a negative fluid balance (−780.4 ± 1720.6 ml/24 h, P = 0.018) 24 h after PICCO than the other three groups. Cardiotonic drug use and dehydration treatment were associated with increased CFI (from 4.1 ± 1.4 /min to 4.5 ± 1.3/min, P = 0.07) and reduced ELVWI (from 11.0 ± 4.7 ml/kg to 9.0 ± 3.5 ml/kg, P = 0.029). Renal function tests showed that SCr and BUN levels in the CVP↓+ CO↑ group were significantly improved (SCr from 197.1 ± 128.9 mmol/L to 154.4 ± 90.8 mmol/L; BUN from 14.3 μmol/L ± 7.3 to 11.6 ± 7.0 μmol/L, P < 0.05).Conclusions: Lower CVP was associated with increased CO, which may improve the 28-day prognosis in patients with circulatory shock. Notably, higher CO derived from lower CVP may also contribute to renal function improvement.

Low Central Venous Pressure vs Goal Directed Fluid Therapy During Liver Surgery

Low Central Venous Pressure vs Goal Directed Fluid Therapy During Liver Surgery

Pre-, Intra-, and Post-Operative Factors for Kidney Injury of Patients Underwent Cardiac Surgery: A Retrospective Cohort Study.

BackgroundKidney injury is common in patients who have undergone cardiac surgery, and it has high morbidity and mortality. The objective of the study was to identify pre-, intra-, and post-operative risk factors responsible for kidney injury among patients who had undergone cardiac surgery.Material/MethodsPatients (n=1468) who had undergone cardiac surgery were stratified into those with kidney injury (n=488) and those without kidney injury (n=980) using the KDIGO (Kidney Disease: Improving Global Outcomes) criteria. Data of pre-, intra- and post-operative variables were collected and analyzed.ResultsAcute kidney injury occurred in 33.2% of study patients. Patients with post-operative acute kidney injury had older age, comorbidities, higher preoperative serum creatinine, coronary artery bypass grafting, longer operation time, high cardiopulmonary bypass and cross-clamping time, low central venous pressure, and prolonged mechanical ventilation as compared to patients without kidney injury (P<0.05 for all). Age >65 years (OR 1.4), preoperative hypertension (OR 2.0), preoperative anemia (OR 2.3), preoperative low ejection fraction (OR 3.7), Charlson comorbidity index >2 (OR 2.5), longer cardiopulmonary bypass time (OR 4.0), blood transfusions (OR 2.1), postoperative hypotension (OR 5.2), and low central venous pressure (OR 8.1) were responsible for kidney injury. Mortality of patients with kidney injury was significantly higher than those without acute kidney injury (52 versus 1, P<0.001).ConclusionsAppropriate and effective control of pre-, intra-, and post-operative variables can reduce the risk of kidney injury development in patients following cardiac surgeries.

Impact of a goal directed fluid therapy algorithm on postoperative morbidity in patients undergoing open right hepatectomy: a single centre retrospective observational study

BackgroundRight hepatectomy is a complex procedure that carries inherent risks of perioperative morbidity. To evaluate outcome differences between a low central venous pressure fluid intervention strategy and a goal directed fluid therapy (GDFT) cardiac output algorithm we performed a retrospective observational study. We hypothesized that a GDFT protocol would result in less intraoperative fluid administration, reduced complications and a shorter length of hospital stay.MethodsPatients undergoing hepatectomy using an established enhanced recovery after surgery (ERAS) programme between 2010 and 2017 were extracted from a prospectively managed electronic hospital database. Inclusion criteria included adult patients, undergoing open right (segments V-VIII) or extended right (segments IV-VIII) hepatectomy. Primary outcome: amount of intraoperative fluid administration used between the two groups. Secondary outcomes: type and amount of vasoactive medications used, the development of predefined postoperative complications, hospital length of stay, and 30-day mortality. Complications were defined by the European Perioperative Clinical Outcome definitions and graded according to Clavien-Dindo classification. The association between GDFT and the amount of fluid and vasoactive medication used was investigated using logistic and linear regression models.ResultsFifty-eight consecutive patients were identified. 26 patients received GDFT and 32 received Usual care. There were no significant differences in baseline patient characteristics. Less intraoperative fluid was used in the GDFT group: median (IQR) 2000 ml (1175 to 2700) vs. 2750 ml (2000 to 4000) in the Usual care group; p = 0.03. There were no significant differences in the use of vasoactive medications. Postoperative complications were similar: 9 patients (35%) in the GDFT group vs. 18 patients (56%) in the Usual care group; p = 0.10, OR: 0.41; (95%CI: 0.14 to 1.20). Median (IQR) length of stay for patients in the GDFT group was 7 days (6:8) vs. 9 days (7:13) in the Usual care group; incident rate ratio 0.72 (95%CI: 0.56 to 0.93); p = 0.012. There was no difference in perioperative mortality.ConclusionsIn patients undergoing open right hepatectomy with an established ERAS programme, use of GDFT was associated with less intraoperative fluid administration and reduced hospital length of stay when compared to Usual care. There were no significant differences in postoperative complications or mortality.Trial registrationAustralian New Zealand Clinical Trials Registry: no12619000558123 on 10/4/19.

THE ROLE OF INFERIOR VENA CAVA DIAMETER VARIATION RATIO MEASURED BY ULTRASONOGRAPHY VERSUS CENTRAL VENOUS PRESSURE IN ASSESSMENT OF VOLUME RESPONSIVENESS OF SHOCKED HEPATIC PATIENTS

Background: Liver cirrhosis is a major cause of morbidity and mortality in chronic liver disease patients which is multifactorial in nature, leading to several complications including ascites, variceal bleeding, hepatic encephalopathy and hepatorenal syndrome. Aim of the study: to evaluate the relationship between inferior vena cava (IVC) diameter variation ratio measured by ultrasonography (USG) versus central venous pressure as measured via central venous catheter, and whether it is reliable for use in evaluating intravascular volume status during the management of shock in hepatic patients. Patients and Methods: This study included one hundred cirrhotic liver patients with Child-Pugh classification B and C with acute circulatory failure of either sex, aging ≥18 years old, admitted in the ICU at Ain Shams University hospitals. A standard resuscitation strategy was applied. The patients were monitored using mean arterial blood pressure (MAP), heart rate (HR), central venous pressure (CVP) and ultrasound guided IVC collapsibility index (IVCCI) simultaneously at baseline and along the subsequent stages of standard shock management protocol at intervals 1, 4 and 8 hours. Results: The current study showed that 77 patients (77%) responded to volume resuscitation with improvement as regard elevated MAP with maximal mean value of 67.34 (±4.01) mmHg., decreased HR with minimal mean value of 103 (±4.89) b/min., elevated central venous pressure with maximal mean value of 9.05(±2.07) cmH2O and decreased IVC- CI with minimal mean value of 0.64 (±0.05) after 8 hours of volume management, these patientswere considered volume responders., while 23 patients (23%) didn’t respond to volume resuscitation with no response or even deterioration as regard low MAP with maximal mean value of 49.61 (±3.56) mmHg., high HR with minimal mean value of 133 (±4.86) b/min., low central venous pressure with maximal mean value of 2.17 (±0.78) cmH2O and low fixed IVC- CI with minimal mean value of 0.39 (±0.06) after 8 hours of volume management, despite maximal possible volume of fluid resuscitation necessitating use of vasopressor agents, these patients were considered volume non responders.Conclusion: Measurements of CVP and IVC-CI throughout the study in volume responder patients were found to have a solid negative correlation denoting that Inferior Vena Cava collapsibility index assessment is a safe option being non invasive technique and sensitive at least when compared to measuring CVP and to avoid complications of central venous line (CVL) insertion with its complications especially in hepatic patients with coagulopathy.

Doppler Recognition of Low or Normal Central Venous Pressure from Continuous Flow from Inferior Vena Cava Into Right Atrium

Estimation of right atrial (RA) or central venous pressure (CVP) is a critical component of a comprehensive transthoracic echocardiographic (TTE) examination. We hypothesize that continuous inflow from the inferior vena cava (IVC) into the RA is a surrogate for low/normal CVP and can be reliably imaged in standard echocardiographic parasternal short and right ventricular inflow views. We retrospectively studied 200 patients who underwent right heart catheterization (RHC) within 8 hours of TTE between 2012 and 2016, and selected 60 patients in whom the continuous wave Doppler beam incidentally interrogated IVC inflow into RA during evaluation of the tricuspid valve. From these studies, we sought an uninterrupted Doppler wave (DW) inflow signal. CVP on RHC were then compared in patients with continuous and interrupted DW. Other TTE and RHC parameters were also noted and compared in these 2 groups. The average time interval between TTE and RHC was 266 ± 151 minutes. Of 60 patients (males = 39 (65%); age 63 ± 14 years), 12 patients (20%) had continuous DW and 48 (80%) had interrupted DW inflow signal from IVC into the RA. Of the 12 patients with continuous flow, 11 had RA pressure of ≤7 mm Hg. Similarly, of 48 patients with interrupted flow, RA pressure was >7 mm Hg in 45, and less than ≤7 mm Hg in 3 patients (two-sided p value 0.0001). The continuous DW signal predicted RA of ≤7 mm Hg with a sensitivity and specificity of 98% and 78%, respectively. Additionally, when combined with IVC size and collapsibility (normal-sized collapsible IVC), the sensitivity and specificity of DW signal to predict RA of ≤ 7 mmHg were enhanced to 94% and 92%, respectively. In conclusion, IVC flow pattern can be reliably studied to estimate CVP in standard echocardiographic views. Continuous and interrupted IVC flow predicts normal and elevated RA pressure, respectively.

Bedside hand vein inspection for noninvasive central venous pressure assessment

Rapid estimates of the central venous pressure (CVP) can be helpful to administer early fluid therapy or to manage cardiac preload in intensive care units, operating rooms or emergency rooms in order to start and monitor an adequate medical therapy. Invasive CVP measurements have inherent and non-negligible complication rates as well as great expenditures. Several noninvasive methods of CVP measurements, like ultrasound-guided techniques, are available, but require trained skills and special equipment which might not be at hand in all situations.Our purpose was to evaluate the feasibility and accuracy of CVP estimates assessed upon the height of hand veins collapse (HVC) using invasively measured CVP as the gold standard.The HVC was determined by slowly lifting the patient's hand while watching the dorsal hand veins to collapse. The vertical distance from the dorsal hand to a transducer air zero port was noted and converted to mmHg. The observer was blinded to the simultaneously measured CVP values, which were categorized as low (<7 mmHg), normal (7–12 mmHg) and high (>12 mmHg).Measurements were performed in 82 patients who had a median [IQR] age of 67 [60;74]. Median CVP was 12 [8;15] mmHg and the median absolute difference between the measured HVC and CVP was 4 [2;7] mmHg. The Spearman correlation coefficient between CVP and HVC was 0.55, 95%-CI [0.35;0.69]. Overall CVP categorization was correct in 45% of the cases. HVC had a sensitivity of 92% for a low CVP with a negative predictive value of 98%. A high HVC had a sensitivity of 29% but a high specificity of 94% for a high CVP.The overall performance of observing the hand vein collapse to estimate CVP was only moderate in the intensive care setting. However, the median difference to the CVP was low and HVC identifies a low CVP with a high sensitivity and excellent negative predictive value.

Long-term results of ventricular septation for double-inlet left ventricle†

To review the long-term surgical outcomes of ventricular septation for double-inlet left ventricle and reconsider the possibility of ventricular septation as an option of surgical treatments. Between 1978 and 1994, 22 patients with double-inlet left ventricle underwent ventricular septation. The mean age at operation was 5.3 years (range 0-22 years). Follow-up was carried out in 20 of 22 patients (91%) and the mean follow-up period was 14.7 years (range 0-39 years). Actuarial survival and reoperation-free survival rates at 30 years were 49% and 21%, respectively. To date, 8 patients have been followed up. Among them, atrioventricular valve replacement and permanent pacemaker were required in 4 and 7 patients, respectively. Late cardiac catheter examination at 25.5 years after surgery showed that the median cardiac index was 2.6 l/min/m2 (range 2.1-3.4 l/min/m2), left ventricular end-diastolic pressure was 7 mmHg (range 4-11 mmHg), left ventricular ejection fraction was 50% (range 27-63%), right ventricular ejection fraction was 53% (range 31-66%) and central venous pressure was 6 mmHg (range 4-11 mmHg). At the latest follow-up, the New York Heart Association Functional Classification was I for 5 patients, II for 2 patients and III for 1 patient. The median peak oxygen uptake was 52.9% (range 44.1-93.5%). Some patients with double-inlet left ventricle were able to maintain low central venous pressure and a sufficient cardiac index long after ventricular septation. Although the single ventricle strategy remains a first-line treatment, ventricular septation can be a surgical treatment option.

Benefits of Ultra-Fast-Track Anaesthesia after HeartMate 3 Implantation: A Pilot Study

Purpose Avoidance of invasive ventilation after cardiac surgery is an attractive method to reduce the length of hospital stay and related complications. However there is limited experience about ultra-fast track anaesthesia (UFTA) in patients with end stage heart failure after left ventricular assist device (LVAD) implantation. This study aimed to investigate the outcomes of UFTA with extubation in operating theatre in patient receiving HeartMate 3 (HM3) implantation. Methods This study was an observational study. Between October 2015 and December 2017 all elective eligible patients for HM3 implantation in our department were included in this study. Exclusion criteria for UFTA were, inter alia, INTERMACS 1 and 2, preoperative invasive ventilation or forced expiratory volume in 1 second (FEV1) Results 45 patients received HM3 implantation in the mentioned period and 36 patients were eligible for UFTA. UFTA was successfully performed in 27.7 %. Distribution of preoperative risk factors was similar between groups. Patients in UFTA group had significantly lower incidences of pneumonia (p =0.001), septic shock (p=0.045) and right ventricular failure (RVF) (p=0.024). They showed a significantly higher cardiac index in the first 24h. (p=0.012); a significantly lower central venous pressure during the first 24h. postoperatively (p=0.005) and a significantly better central venous saturation after the first 6h postoperatively and continuing to 24h postoperatively (p=0.011). Additionally, intensive care unit (ICU) stay (p=0.006) was significantly shorter in the UFTA group. Kaplan-Meier analysis revealed no significant difference in the 30-days survival. Conclusion In this pilot study, we demonstrated the feasibility of ultra-fast-track anesthesia in HM3 patients with INTERMACS level 3-4. Patients had a lower incidence of postoperative complications, better hemodynamic performance, and shorter length of ICU stay and lower incidence of RVF after UFTA. Prospective investigations are encouraged to evaluate the capability of UFTA for sustainable protection of right ventricular function, and these studies should aim to identify useful criteria for adequate patient stratification.

Enhanced recovery after surgery in liver resection: current concepts and controversies.

Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.

Impact of intraoperative hypovolemic phlebotomy on blood loss and perioperative transfusion in patients undergoing hepatectomy for cancer

Background: Intraoperative blood loss (IOBL) and allogeneic blood transfusion are important determinants of outcome in patients undergoing elective hepatectomy for cancer. We assessed whether intraoperative hypovolemic phlebotomy (HP) used to perform hepatectomy under low central venous pressure (CVP) was associated with lower IOBL and perioperative transfusion rates, and whether these factors were linked to patient oncological outcomes. Methods: Restrospective analysis of a prospectively maintained database of consenting patients who underwent hepatectomy for primary and secondary liver malignancies between 01/2011 and 06/2017 in one academic center. Perioperative blood transfusion was defined as red blood cell unit transfused during hepatectomy until hospital discharge, and data were extracted from the hospital transfusion medicine database. We used the Fisher’s exact test to compare proportions, the Mann-Whitney or the Kruskal-Wallis tests to compare means, the Spearman r test for correlations, and Log Rank test and Cox regression for associations of variables with survival outcomes. Results: Intraoperative HP was used in 520 (76.0%) of the 684 patients included in this study. The median phlebotomy volume was 400 ml (range 50 to 900 ml), and median volume per patient weight was 5.3 ml/kg (range 0.5 to 30.1 ml/kg). Patients with large HP (>5.3 ml/kg) had lower IOBL than those with smaller HP (507 ml vs. 640.2 ml, p = 0.008). HP volume/weight was negatively correlated with IOBL (Spearman r = -0.11, p = 0.019). The perioperative transfusion rate was 14.6% in patients when HP was used, compared to 22.2% (p = 0.022) when HP was not used. The transfusion rate was lower in HP patients compared to non-HP patients even though more major hepatectomies (≥4 segments) (36.0% vs. 27.1%, p = 0.02) and less laparoscopic surgery (4.9% vs. 11.1%) were done in the HP group. Intraoperative HP reduced the perioperative transfusion risk by 8.9% (relative risk 0.91, 95% CI 0.82 to 0.99), and the number needed to treat to avoid one transfusion was 13 patients. The preoperative three-point transfusion risk score (hemoglobin 12.5 g/dl or less, primary liver malignancy, and resection of ≥ 4 liver segments) stratified patients by low vs. high transfusion requirements (13.3% if score 0 or 1 vs. 31% if score 2 or 3, p < 0.0001), irrespective of the use of HP. We did not find a significant association between IOBL or perioperative transfusions and recurrence-free or disease-specific survival. Conclusion: Intraoperative HP in patients undergoing hepatectomy was associated with lower IOBL and a perioperative transfusion rate of 14.6%, which was lower than non-HP patients and the 22% to 32% rate reported in contemporaneous series. Prospective studies with optimized preoperative hemoglobin level, standardized intraoperative hemostatic and fluid management methods, and defined perioperative transfusion criteria are needed to determine whether HP is superior to other anesthesiological techniques of low CVP for reducing IOBL and transfusion requirements.

Invasive central venous monitoring during hepatic resection: unnecessary for most cases

Background: Low central venous pressure (LCVP) improves outcome after hepatic resection and is the standard anesthetic management technique. Historically, this approach required a central venous catheter (CVC), but non-invasive assessment of CVP has evolved and is now routine. This study evaluates the impact of this change in practice and patient outcome after liver resection. Methods: A non-randomized, retrospective, cohort design was conducted using a prospectively maintained database of hepatic resections at our institution from 2007–2016. Infection, major morbidity, and 90-day mortality were compared between the group that received CVC and the group without CVC. Multivariable logistic regression was used for each outcome. CVC was forced into each model to assess association while controlling for other significant factors. Results: During the study period, 2518 hepatic resections were assessed and analyzed over three time periods (2007–2010, 2011–2013 and 2014–2016). CVCs were placed in 16.3% of the patients. The use of CVC was significant for 90-day mortality, 3.40% with CVC verses 1.0% without CVC (p 0.008). Presence of CVC was not significantly related to superficial wound infections (p 0.644), deep wound infections (p 0.389), or major complications (p 0.166) while controlling for other significant factors in the multivariable analysis. In patients submitted to a major resection (≥3 segments), CVC was not used in 75.8% of the cases. The results remained constant over the three time periods analyzed. Conclusion: The evolution to non-invasive assessment of fluid management for patients undergoing partial hepatectomy has not resulted in adverse outcomes.

Automated expiratory ventilation assistance through a small endotracheal tube can improve venous return and cardiac output

BackgroundPositive pressure ventilation can decrease venous return and cardiac output. It is not known if expiratory ventilation assistance (EVA) through a small endotracheal tube can improve venous return and cardiac output.ResultsIn a porcine model, switching from conventional positive pressure ventilation to (EVA) with − 8 cmH20 expiratory pressure increased the venous return and cardiac output. The stroke volume increased by 27% when the subjects were switched from conventional ventilation to EVA [53.8 ± 7.7 (SD) vs. 68.1 ± 7.7 ml, p = 0.003]. After hemorrhage, subjects treated with EVA had higher median cardiac output, higher mean systemic arterial pressure, and lower central venous pressure at 40 and 60 min when compared with subjects treated with conventional ventilation with PEEP 0 cmH20. The median cardiac output was 41% higher in the EVA group than the control group at 60 min [2.70 vs. 1.59 L/min, p = 0.029].ConclusionEVA through a small endotracheal tube increased venous return, cardiac output, and mean arterial pressure compared with conventional positive pressure ventilation. The effects were most significant during hypovolemia from hemorrhage. EVA provided less effective ventilation than conventional positive pressure ventilation.