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Effect

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Effect

    Effect

Effectofcontrolledlowcentralvenouspressureon

    ;renalfunctioninmajorliverresection

    ;YuyongLiu,MingxueCai,Shan’eDuan,XuemeiPeng,YongLai,YalanLi

    ;DepartmentofAnesthesia,TheFirstAffiliatedHospital,IinanUniversity,Guangzhou510630,China

    ;Received:22July2007/Revised:16August2007/Accepted:20September2007

    ;AbstractObjective:Toinvestigatelheeffectsoflowcentralvenouspressure(LvCP)onbloodlOSSandevaluateitsinflu.

    ;enceonrenalfunctioninpatientsundergoinghepatectomy.Methods:Forty.sixpatients.ASAclassificationMlI.undergoing

    ;liverresectionwererandomizedintoLCVPgroup(n=23)andcontrolgroup(n=23).1nLCVPgroup.CVPwasmaintained

    ;al2-4mmHgandMBPabove60mmHgduringhepatectomy,whileincontrolgrouphepatectomywasperformedroutinely

    ;withoulloweringCVP.VolumeofbloodlOSSduringhepatectomy.volumeofbloodlransfusion.andchangesofrenaIfunctions

    ;werecomparedbetweenlhetwogroups.

    esults:Therewerenosignificantdifferencesindemographics.ASAscore.type

    ;ofhepatectomy,durationofinflowocclusion.operationlime.weightofresectedliverlissues,andrenalfunctionsbetweenlhe

    ;twogroups.LCVPgrouphadasignificantlylowervolumeoflotalintraoperativebloodlOSS(P<0.01)andRBClransfusion(P

    ;<O.O5).Conclusio,’LoweringlheCVPlolesslhan5mmHgisasimpleandeffectivetechniqueloreducebloodlOSSand

    ;bloodinfusionduringliverresection,andhasnodetrimentaleffectsonrenalfunctions

    ;Keywordshepatectomy;hepatocellularcarcinoma;lowcentralvenouspressure;bloodloss;renalfunction

    ;Limitingintraoperativebloodlossandtheconsequent

    ;needforwholebloodtransfusionisawidelyaccepted

    ;goalinliverresection_1j.Bloodlossduringliverresection ;constitutestheprimarydeterminantofthepostoperative

    ;outcome.Varioustechniques,suchasPringle’smaneuver

    ;andunilateralhepatichilumocclusion,havebeenusedto

    ;controlbleedingfromhepaticarterialandportalvenous

    ;systemsduringhepatectomyandpreventpostoperative

    ;complications.Effectivecontrolofhepaticvenoushem

    ;orrhageiscrucialtominimizeintraoperativebloodloss.

    ;Thisprospectiverandomizedclinicaltrialaimsatevalu

    ;atingtheroleoflowcentralvenouspressure(LCVP)in

    ;reducingbloodlossduringhepatectomyanditsinfluence ;onrenafunctions.

    ;Materialsandmethods

    ;Subjects

    ;FromJune2004toDecember2006,atotalof46con

    ;secutivepatientswithhepatocellularcarcinoma(30men ;and16women)wereunderwenthepatectomybythe ;samegroupofsurgeonsatourhospita1.Thepatientswere ;blindlyrandomizedintoLCVPgroup(/1=23)andcontrol ;group(/1=23).Thedemographicdataofthepatientswere ;showninTable.

    ;Correspondenceto:YuyongLiu.Email:docyong@126.com ;Anesthesiaandintraoperativemanagement

    ;0narrivalintheoperatingroomofnonpremedicated ;patients,aSolar8000monitor(GE,USA)wasusedto ;monitorcontinuouslytheelectrocardiogram.periphera1 ;oxygensaturation(Sp02),directarterialpressure(radial ;artery),andcentralvenouspressure(rightinternaljugu

    ;larveincannulation),andurineoutput(bladdercatheter) ;wasrecorded.FoHowingi.v.injectionofpropofol(1.52

    ;mg/kg),fentanyl(2pg/kg),andatracurium(0.5mg/kg), ;thetracheawasintubatedandthelungsmechanically

    ;ventilated(Drager,Germany)atafrequencyof112/ ;minandatidalvolumeof8-10mL/kg.Anesthesiawas ;maintainedwithinfusionofpropofol[4_6mg/(kgh)], ;remifentanil[0.25(kgmin)]andbolusdosesofatra

    ;curiumforneuromuscularblockadeinbothgroups.All ;patientsweremechanicallyventilatedtomaintainan ;endtidalcarbondioxideconcentrationintherangeof30 ;to35mmHg.

    ;IntheLCVPgroup,patient’srightinternaliugular

    ;veinwascannulatedbyadua1..channelcatheterfollow——

    ;inganesthesiaforcontinuouslymonitoringCVP.Systolic ;bloodpressure(SBP)wasmaintainedabove90mmHgby ;intravenousinfusionofdopamine(4_6~g/kg)whennec

    ;essary.Duringhepatectomy,CVPwasmaintainedat2-4 ;mmHgbyadoptingTrendelenburg’sposture(withhead

    ;15.lowerthanlowextremities)limitingthevolumeof ;infusionandintravenouslyadministeringnitroglycerine ;

    ;8

    ;(0.52mg),andfurosemide(10-20mg)wasusedintra

    ;venouslyifnecessary.Packedredcellsweretransfused ;whenhemoglobin(Hb)was<80g/Lduringtheopera

;tion.Afterliverresectionandhemostasiswerecomplet

    ;ed,thebloodvolumewasrestoredwithcrystalloidand ;colloidsolutions.PostoperativeHbvalueshouldbekept ;atabove100g/L.Inthecontro1group,patientswereman

    ;agedinthesamewayasthoseinLCVPgroup,exceptfor ;manipulationofpatient’spostureandadministrationof

    ;nitroglycerineandfurosemidetolowerCVP. ;MeasurementofbloodlOSS

    ;Totalintraoperativebloodlosswascalculated:the ;volumeofthecollectedbloodinthebottlewasmeasured ;andal1bloodstainedgauzeswereweighed.Thediffer

    ;encebetweentheweightofthebloodstainedgauzesand

    ;theirinitia1weightwasconsideredastheweightofblood ;inthegauze,whichwasthenconvertedintothevolume ;ofbloodf1.058g/mL).

    ;Parametersandrenalfunctionmonitoring

    ;Thefollowingdatawerecollected:bloodureanitrogen ;(BUN),creatinine(Cr);totalintraoperativeblood1OSS;

    ;operationtime;patternofhepatichilumocclusionand ;duration;maximaltumordimension;weightoftheex

    ;cisedlivertissueandextentofhepatectomy;transfusion ;volumeofpackedRBCandfreshfrozenplasma(FFP);re

    ;nalfunctionsonpostoperativeday1,3and7. ;Table1Comparisonofpatient’scharacteristicsbetweentwogroups

    ;?r,.springerlink.com/content/16139089

    ;Statisticalanalysis

    ;M1datawereexpressedasmean?SD.SPSSsoftware ;packageversion13.0wasusedtorunthestatisticalanal

    ;ysis.Continuousvariableswerecomparedbetweenthe ;twogroupsusingStudent’sttestoratwo—wayANOVA,

    square ;anddescriptivevariableswereanalysedusingchi

    ;(X)test.P<0.05wereconsideredtobestatisticallysig

    ;nificant.

    ;Results

    ;.

    ;orcysixconsecutivepatientswereincludedinthis ;study.Preandintraoperativepatientcharacteristicsare ;showedinTable1.Therewerenosignificantdifierences ;ingender,age,bodyweight,durationofoperation,unne ;outputandgradesofliverfunction(ALTandAST)be

    ;tweenLCVPandcontrolgroups(Table1).

    ;Weightoftheresectedlivertissue,timeforhepatec

    ;tomy,preoperativeandpostoperativehemoglobin(Hb) ;inLCVPgroupwasnotmarkedlvdi1erentfromthose

    ;inthecontrolgroup.TotalintraoDerativebloodlosswas ;dramaticallylessinLCVPgroupthaninthecontrolgroup ;(P<0.01;Tab1e2).SevenpatientsinLCVPgroupand13 ;patientsincontrolgroupneededbloodtransfusion,there ;wasasignificantlylowervolumeofRBCtransfusionin ;LCVPgroupthanincontrolgroup(P<0.05;Tabk2). ;TherewerenosignificantdifierencesinBUNandCr ;onpreandpostoperativeday1,3and7betweenthetwo ;groups(P>0.05;Table3).Theyal1waswithinthenormal ;P>0.05vs.controlgroup

    ;Table2Comparisonofintraoperativeparametersbetweentwogroups ;P<0.05VS.controlgroup;P<0.01vs.controlgroup ;Table3Comparisonofperioperativerenalfunctionsbetweentwogroups

    ;NosignificantdifferencesinBUNandCronpreoperativeandpostoperatived

    ay1,3and7betweentwogroups(P>0.05)

    ;

    ;ChineseGermanIClinOncol,anuary2008,Vo1.7,No.1 ;rangeinbothgroups

    ;Discussion

    ;Hepatectomyisamajorupperabdominalsurgerywith ;potentia1riskofmassiveblood1OSSandsubsequentre- ;quirementforbloodtransfusion,whichiscorrelatedsig

;nificantlywithpostoperativemorbidityandmortality_2.

    ;Achievingandmaintaininghemostasisislargelydepen

    ;dentonsevera1keyfactors,includinganaestheticand ;surgicaltechniques,thequalityoftheliverandintrinsic ;andextrinsicclottingcomponents.

    ;Unilateralhepatichilumocclusionandnormothermic ;tota1hepaticvascularexclusion[3]’havebeenadoptedto

    ;reduceintraoperativebloodloss.

    ;Underhepatichilumocclusion.blood1OSSduring1iver ;resectionmainlyderivesfromhepaticvein.Hepaticsinu

    ;soidalpressureisdirectlyrelatedtoCVP.Withlowering ;ofthepressureininferiorvenacava,thehepaticvenous ;pressureandthenhepaticsinusoidalpressurewouldde

    ;cline.

    ;ItwasreportedthatLCVPduring1iverresectioncould ;significantlycutdowntheintraoperativeblood1OSS,de

    ;creasetheincidenceofpostoperativecomplicationsand ;shortenthehospita1stay,.Muchattentionhasrecently

    ;beendevotedtotherelationbetweenalowcentrMve

    ;nouspressure(CVP)andbloodlossduringliversurgery ;6].

    ;Maintainingalowcentralvenouspressureisbecoming

    ;acommonlyacceptedwayofreducingbloodlossduring ;liverresectionandtheproblemofairembolismcanbe ;easilyeliminatedbykeepingthecentralvenouspressure ;atmorethan0mmHg.Inthisway,thereisnoriskofpul

    ;monaryembolismevenwithinjurytotheinferiorvena ;cava[1.

    ;Conflictingreportsexistwithrespecttotheassocia

    ;tionbetween1owCVPandrena1failure,8_.Inourstudy,

    ;9

    ;bymaintainingCVPbetween2——4mmHgduringliver

    ;resectionwithmanipulationofpatient’sposture,admin—

    ;istrationofdrugsandcontrolofinfusionspeed,thear- ;teria1pressurewaseffectivelysustainedandblood1OSS ;wasmarkedlycutdown.Thepostoperativeevaluation ;showedthatLCVPwouldnotdeterioraterenalfunctions. ;Ourresultsshowedthattota1intraoperativeblood1OSS

    ;wasmarkedlylessinLCVPgroupthanthatinthecontrol ;group.ItsuggestedthatloweringCVPduringhepatec

    ;tomycouldeffectivelvreducebloodloss.Additionally, ;transfusionvolumewasmarkedlycutdowninLCVPas ;comparedwiththecontrolgroup.

    ;4

;TorzilliG,MakuuchiM,Midorikawaefa1.Liverresectionwithout

    ;10talvascularexclusion:hazardOUSorbeneficial?Ananalysisofour ;experience.AnnSurg,2001,233:167175.

    ;GozzettiG,MazziottiA,GraziGL,efa1.Liverresectionwithoutblood ;transfusion.BrJSurg.1995.82:1105_-1110.

    ;LaiJM.LiangLJ.LiDM.Applicationofhepatovascularocclusionin ;hepatocellularcarcinomaresection.ChinJBasesClinGeneralSurg ;(Chinese),1999,6:217219.

    ;JohnsonM.MannarR,WuAV.CorrelationbetweenbloodlOSSand ;inferiorvenacavalpressureduringliverresection.BrJSurg,1998, ;85:188190.

    ;SmyrniotisV.KostopanagiotouG,TheodorakiK,efa1.Theroleof ;centralvenouspressureandtypeofvascularcontrolinbloodlOSS ;duringmajorliverresections.AmJSurg.2004,187:398_402. ;JonesRM.MoultonCE,HardyKJ.Centralvenouspressureand ;itseffectonbloodlOSSduringliverresection.BrJSurg,1998,85: ;10581060.

    ;MassicotteL.LenisS,ThibeaultL,efa1.Effectoflowcentralvenous ;pressureandphlebotomyonbloodproducttransfusionrequirements ;duringlivertransplantations.LiverTranspl.2006,12:117123.

    ;SchroederRA,CollinsBH,TuttleNewhallE,efa1.Intraoperativefluid

    ;managementduringorthotopiclivertransplantation.JCardiothorac

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