Changes in hemodynamics in end stage liver failure patients after liver transplantation
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Objective:To investigate the changes in hemodynamics in end stage liver failure patients after liver transplantation.Methods:Five patients with liver transplantation were included in this study.SwanGanz catheters were inserted and central venous pressure (CVP),mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP),cardiac output (CO),mean arterial pressure (MAP),systemic vascular resistance index (SVRI),pulmonary vascular resistance index (PVRI),heart rate (HR) were measured from 1 to 3 days after the operation.Results:MAP,PCWP,and CVP decreased and HR increased after the admission to ICU,and then they were increased within 3 days.Cardiac index(CI) showed no marked changes within 3 days.SVRI and PVRI were decreased at the admission,and then were improved in the next 3 days.Conclusions:In end stage liver failure patients with liver transplantation,the hemodynamics is unstable,indicating hypovolemia.It is necessary to calculate the volume deficit and determine the resuscitation volume.Keywords:
Pulmonary wedge pressure
Cardiac index
Hypovolemia
Mean arterial pressure
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Objective To describe the hemodynamic changes during piggyback liver transplantation (PBLT), and to analyze the hemodynamic correlation with various degrees of cirrhosis according to Childpugh classification. Methods Between March 1999 and June 2004, 180 patients underwent PBLT procedure in our institution, and 95 cases were selected and divided according to Child classification. The intraoperative hemodynamics of different time points were retrospectively analyzed, including mean artery pressure (MAP), heart rate (HR), central vein pressure (CVP) and mean pulmonary artery pressure (MPAP). Results Hemodynamic changes were minimal before and during anhepatic phase in all the patients. At reperfusion, a hemodynamic disturbance occurred featured by decrease of MAP and increase of MPAP. Comparison between different Child class showed that in the Child C group, MAP were lower and HR were higher before new liver phase, while CVP and MPAP were higher during new liver phase. Conclusion Hemodynamic changes were minimal before and during anhepatic phase for PBLT, while they were more severe during reperfusion, and they also correlates with the different Child class before transplantation. The more severe of the cirrhosis before transplantation according to Child classification, the greater hemodynamic changes during the operation.
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BackgroundFluid resuscitation in early post-operative (PO) period after liver transplantation (LT) can be very detrimental for both graft and patient's outcome. Central venous pressure (CVP) was commonly used to guide fluid resuscitation after LT; yet, volumetric indices like stroke volume (SV) or right ventricular end diastolic volume (RVEDV) have gained more support recently. We tested the hypothesis that use of any of the three parameters to guide fluid therapy in the early PO period after living donor liver transplantation (LDLT) will not elaborate any changes in fluid volumes infused or graft and patient outcome.Patients and methodsSixty patients undergoing LDLT allocated based on the parameter guiding the fluid therapy in the first 72 h in ICU into one of three groups, G-CVP (control), G-SV and G-RV groups 20 patients each using CVP, SVI and RVEDVI respectively to guide fluid therapy. Based on the guiding parameter assessed every 4 h, fluid therapy was administered as 500 ml boluses followed by reassessment of the guiding parameter for further fluid infusion. Fluids infused over three days in the ICU were used as a primary outcome. Hemodynamics, graft and renal functions, and graft and patient outcome were recorded as secondary objectives.ResultsCVP and PCWP were significantly higher in G-SV and G-RV compared to the CVP group while other hemodynamic parameters did not show significant differences between the groups. Fluid volume infused and urine output were significantly higher in G-SV and G-RV compared to G-CVP group. Laboratory and survival data did not differ among the studied groups.ConclusionThe use of the CVP to guide fluid infusion after LT is a safe and effective alternative to more logistically demanding techniques as SV and RVEDVI without any negative impact on patient hemodynamic or metabolic homeostasis.
Intravascular volume status
Fluid Replacement
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Objectives To evaluate the application of volumetric pulmonary artery catheters in liver transplantation. Methods Twenty patients suffered from end phase hepatopathy and they were scheduled for liver transplantation under general anesthesia, volumetric pulmonary artery catheters were placed through right internal jugular vein, the hemodynamic data, including heart rate(HR), mean arterial pressure (MAP),central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), stroke volune index (SVI), systemic vascular resistance index (SVRI), pulmonary vascular resistance index (PVRI), right ventricular end-diastolic volume index (RVEDVI), were recorded at five measurement points of after anesthesia, anhepatic phase 15 min, anhepatic phase 30 min, reperfusion phase, before end of the surgery. Results Compared with postanesthesia value, MAP was decreased in anhepatic phase (P0.05), PCWP,CVP, RVEDVI, CI and SvO2 were apparently decreased in anhepatic phase(P0.01). RVEDVI was apparently correlated with CI at all time points(P0.01), PCWP was apparently correlated with CI in anhepatic phase(P0.01),CVP was apparently correlated with CI in reperfusion phase (P0.01). Conclusions In liver transplantation, volumetric pulmonary artery catheters can provide overall hemodynamic data which assists in evaluation of circulation functions and guides drug and volume treatment.
Pulmonary wedge pressure
Pulmonary artery catheter
Cardiac index
Mean arterial pressure
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Objective To assess the optimal level of positive end expiratory pressure (PEEP) in the treatment of res piratory failure patients who underwent successful orthotopic liver transplantation.Methods Four chosen levels of PEEP (0cm H 2O, 5cm H 2O, 10cm H 2O and 15cm H 2O) were studied in three patients who were intubated and mechanically ventilated with PEEP because of progressive and severe hypoxia in the immediate postoperative period, each level lasting 20 minutes.Arterial blood gas analyses, direct mean arterial pressure (MAP), central venous pressure (CVP), graft size, portal venous diameter and velocity of portal venous blood flow were measured. After completion the measurement of all four PEEP levels for each patient, an optimal level of PEEP chosen should be of excellent PaCO 2 and PaO 2 level(PaCO 2 4-5kPa, PaO 210kPa) and have no any serious interference with the systemic hemodynamics and transplanted liver.Results ①The PaO 2 reached a best level on 10cm H 2O of PEEP and other parameters such as MAP,CVP, transplanted liver size, portal venous diameter and velocity of portal venous blood flow showed no significant changes. When the level raised to 15cm H 2O, the PaO 2 wasn't improved anymore but the CVP and velocity of portal venous blood flow altered significantly. The CVP increased [(7.6±3.8)cm H 2O at 0cm H 2O PEEP vs (12.6±4.5)cm H 2O at 15cm H 2O PEEP] and portal venous blood flow decreased [(83±11)cm H 2O vs (55±13)cm H 2O respectively] significantly. Other parameters such as MAP, liver size, portal venous dimension only changed slightly. ② The 11 12cm H 2O PEEP was suitable proper for each of the three patients. In this pressure, patients can keep a good PaO 2 level and the MAP and CVP have no significant changes.Conclusions ① In the treatment of respiratory failure patients using PEEP after orthotopic liver, 11-12cm H 2O pressure is appropriated. ②The PEEP above 15cm H 2O may exert marked detrimental effects on CVP and portal venous blood flow.
Positive End-Expiratory Pressure
Venous blood
Arterial blood
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To investigate the effect of pulmonary vascular dysfunction in the prognosis of patients with acute lung injury (ALI).Patients with ALI who underwent pulmonary artery catheterization in the department of critical care medicine of Wuhan NO.1 Hospital from June 2017 to June 2019 were enrolled. The general information, clinical and hemodynamic indexes [central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), pulmonary artery systolic pressure (sPAP), pulmonary artery diastolic pressure (dPAP), mean pulmonary artery pressure (mPAP), cardiac index (CI)], acute physiology and chronic health evaluation II (APACHE II) score, arterial blood gas parameters [pH, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), oxygenation index (PaO2/FiO2)], whether there was shock or not; ventilator parameters [platform pressure (Plat), positive end-expiratory pressure (PEEP)], etc. were recorded. Pulmonary artery oxygen saturation, pulmonary vascular function indexes [transpulmonary potential gradient (TPG) and pulmonary vascular resistance index (PVRi)] were calculated. The relationship between TPG, PVRi and mechanical ventilation time, the length of intensive care unit (ICU) stay, cardiovascular days and 60-day mortality were analyzed in patients with different prognosis of 60-day and whether the TPG increased (≥ 12 mmHg was defined as elevated TPG, 1 mmHg = 0.133 kPa).A total of 65 patients were included in the study, including 30 males and 35 females; aged (48.9±15.2) years old. Forty-eight cases survived in 60-days, 17 died, and the 60-day mortality was 26.2%. At the baseline, there were no significant differences in cardiopulmonary function measurements, such as CVP, sPAP, dPAP, PAWP, CI, etc. between the two groups of patients with different prognosis. The APACHE II score, shock ratio, TPG and PVRi of the death group were significant higher than those of the survival group [APACHE II: 34±9 vs. 28±11, shock: 52.9% vs. 25.0%, TPG (mmHg): 16.2±1.9 vs. 14.6±2.1, PVRi (kPa×s×L-1): 31.8±4.2 vs. 29.7±3.5, all P < 0.05]. The 60-day mortality of 47 patients with TPG ≥ 12 mmHg was significantly higher than that of 18 patients with TPG < 12 mmHg (34.0% vs. 5.6%), and the mechanical ventilation time and the length of ICU stay were also significantly longer (days: 17±9 vs. 11±8, 16±5 vs. 12±5), and the cardiovascular days also increased significantly (days: 23±7 vs. 18±6), and the differences were statistically significant (all P < 0.05). Pearson correlation analysis showed that PVRi was significantly correlated with mechanical ventilation time, the length of ICU stay and cardiovascular days (r1 = 0.317, P1 = 0.030; r2 = 0.277, P2 = 0.005; r3 = 0.285, P3 = 0.002). In the individual multivariate Logistic regression model, the highest PVRi was an independent risk factor for the 60-day mortality [odds ratio (OR) = 30.5, 95% confidence interval was 20.4-43.1, P = 0.023].Pulmonary vascular dysfunction is common in ALI patients and is independently associated with adverse outcomes.
Pulmonary wedge pressure
Cardiac index
Transpulmonary pressure
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Objective To evaluate the cardiac function of the patients with liver cirrhosis before orthotopic liver transplantation(OLT)using Swan-Ganz catheter.Methods Sixty ASAⅡ-Ⅳ patients aged 45-64 yr with liver cirrhosis scheduled for OLT without veno-venous bypass were allocated into 2 groups according to preoperative liver function:compensated group(group C,n=28)and decompensated group(group H,n=32).Anesthesia was induced with midazolam 3-5 mg,fentanyl 0.15-0.2 mg,propofol 1 mg/kg and vecuronium 0.1 mg/ks and maintained with 0.5%-3.0% isoflurane,fentanyl 0.05-0.10 mg and vecuronium 4 mg/h.The patients were mechanically ventilated after tracheal intubation,and P_(ET)CO_2 was maintained at 30-45 mm Hg.Radial artery was cannulated and Swan-Ganz catheter was placed via right internal jugular vein for monitoring of mean arterial pressure(MAP),cardiac output(co),cardiac index(CI),right ventricular ejection fraction(RVEF),mean pulmonary arterial pressure(MPAP),pulmonary arterial wedge pressure(PAWP),right atrial pressure(RAP),right ventricular end-diastolic volume(RVEDV),fight ventricular end-systolic volume(RVESV)and stroke volume index(SVI).Right and left ventricular stroke work index(RVSWI,LVSWI)and systolic and pulmonary vascular resistance(SVR,PVR)were calculated.Results CO,CI,SVI,MPAP,PAWP,RVEDV,RVESV,RVSWI and LVSWI were significantly elevated in group H as compared with group C indicating hyper-hemodynamic state.The SVR and PVR were significantly decreased in group H.There was no significant difference in HR,MAP,RAP and RVEF between the two groups.Conclusion The patients with decompensated liver function before OLT are in a hyper-hemodynamic state.More attention should be paid to perioperative myocardial protection.
Key words:
Catheterization,Swan-Ganz; Liver transplantation; Liver cirrhosis; Heart function tests
Cardiac index
Pulmonary wedge pressure
Mean arterial pressure
Midazolam
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Pulmonary wedge pressure
Cardiac index
Mean arterial pressure
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