Fluid restriction for liver resection

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Today the surgeon requested that we keep the CVP at 5 or less in order to decrease intraop bleeding/hepatic congestion for hepatic lobectomy for colon ca mets. Ok fine. Kept the CVP at 4-5 the whole time.

Bowel prepped. The patient (50 y/o female, 75kg, no CAD/HTN/DM) lost about 1.5 liters of blood, 1 liter of it within a 5 minute stretch. 4 hour case. She bought a unit prbc, 6.5 L crystalloid, 500 hespan. Ending hb 9.1. BP 100/50 at end with HR 110 (starting pressure 130/60) CVP 5. UOP 200. Extubated no other issues except some diaphragmatic pain (was on sufenta ggt).

It would have been nice to have some intravascular reserve up front for the big volume loss. I had to play catch up with the cordis and blasts of neo for longer than I wanted to.

Anyhoots, do any of you know of any improved outcomes data for this? Has this been requested of you for this type of case? Juz curous.
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Never had the request but a quick google found this.Abstract
[SIZE=+1]Background[/SIZE]Blood loss and transfusion requirement are major determinants of mortality and morbidity following liver resection. This study was prompted by the observation that blood loss was excessive when the inferior vena cava (IVC) was distended, and determined whether a correlation exists between blood loss and pressure within the IVC during liver resection.
[SIZE=+1]Methods[/SIZE]A 6-month prospective study was conducted on 20 consecutive patients undergoing liver resection in which two variables were measured, the pressure within the retrohepatic part of the IVC and blood loss during resection.
[SIZE=+1]Results[/SIZE]It was observed that when the caval pressure was less than 6 mmHg the operating field was almost bloodless (mean blood loss 363 (range 305-465) ml). When the caval pressure was between 6 and 12 mmHg the liver became congested and bleeding from the liver surface became significantly greater (1259 (range 415-1789) ml). When caval pressure was greater than 13 mmHg bleeding became excessive (2703 (range 2360-3450) ml). Correlation between blood loss and caval pressure was strong (Pearson correlation coefficient 0·93, P < 0·001).
[SIZE=+1]Conclusion[/SIZE]This study suggests that one of the keys to decreasing blood loss and transfusion requirement during liver resection is to lower pressure within the IVC. © 1998 British Journal of Surgery Society LtdAccepted: 12 June 1997 Digital Object Identifier (DOI)
10.1046/j.1365-2168.1998.00570.x About DOI


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I'm not a liver guy but I have taken some lectures were they advocated fluid restriction, for the same reasons, during liver resection. Some people advocate it for liver transplants too but thats harder to accomplish.
 
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one of our very good liver surgeons requests a CVP of 5 or less on his cases and we try to comply if the patient will tolerate. If they won't, I just move the transducer a little to keep him happy.

A great surgeon won't lose much blood even with a big partial liver whack, but unfortunately it can be quite bloody at times.

I'll usually have some NTG in the room, but generally get by with limiting fluids to about a liter of crystalloid initially and then maybe a little colloid until he's done with his resection. Then he doesn't care what the CVP is so I can finish resuscitating them.


The thing is he doesn't lose much blood anyways so I'm not sure what outcome he is trying to improve with a lower CVP. If the CVP was 10, his EBL would still only be 300-400 for most of his partial livers so I don't think we are making much of a difference.
 
this is true also for transplant. maintaining a low cvp during dissection phase decreases blood loss (with a good surgeon). I remember seeing a study out of toronto on this even using preop phlebotomy. neo with or without vasopressin to maintain sbp. No increased complications. These guys were real good though - almost never transfusing. Our transplant surgeons give us a bloodbath every time.
 
Mman said:
one of our very good liver surgeons requests a CVP of 5 or less on his cases and we try to comply if the patient will tolerate. If they won't, I just move the transducer a little to keep him happy.
Click to expand...

so you just fudge it? that's ethical.
 
We do cvp 4 or less.

We run 3% saline with 1 1/2% acetate 1 1/2% chloride at 125 cc/o. Check Na every hr or so. It rarely budges. The acetate seems to buffer the acidosis that u would think would develop. We give a few units sometimes, a liter or so of crystal. After they are done with the resection and have hemostasis, I begin loading the pt back up with crystalloid (still keeping in goal extubation). I usually get 1-2 liters in at the end of the case.

I have done this a few times but we do nearly all our resections this way.

Postop I think goes reasonably well. I heard rumor of rebound hyernatremia postop but dont know for sure...
 
We often run our other big belly cases this way too


DrDre' said:
We do cvp 4 or less.

We run 3% saline with 1 1/2% acetate 1 1/2% chloride at 125 cc/o. Check Na every hr or so. It rarely budges. The acetate seems to buffer the acidosis that u would think would develop. We give a few units sometimes, a liter or so of crystal. After they are done with the resection and have hemostasis, I begin loading the pt back up with crystalloid (still keeping in goal extubation). I usually get 1-2 liters in at the end of the case.

I have done this a few times but we do nearly all our resections this way.

Postop I think goes reasonably well. I heard rumor of rebound hyernatremia postop but dont know for sure...
Click to expand...
 
Found these references:

Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. British Journal of Surgery 1998;85:1058-1060.

Melendez JA, Arslan V, Fischer ME, et al. Perioperative Outcomes of Major Hepatic Resections under Low Central Venous Pressure Anesthesia: Blood Loss, Blood Transfusion, and the Risk of Postoperative Renal Dysfunction. Journal of the American College of Surgeons 1998;187:620-625.

“The role of central venous pressure and type of vascular control in blood loss during major liver resection,” V. Smyrniotis et al, Am J Surg, 2004; 187: 398-402.
 
gasnewby said:
so you just fudge it? that's ethical.
Click to expand...


What the heck does that mean?! How is it unethical to let the surgeon believe what he wants? Most of those guys don't know anything about physiology; i.e. that what they are requesting can actually be BAD for the patient. We do what's in the best interest of OUR PATIENT, not what's best for the surgeon...
 
leaverus said:
What the heck does that mean?! How is it unethical to let the surgeon believe what he wants? Most of those guys don't know anything about physiology; i.e. that what they are requesting can actually be BAD for the patient. We do what's in the best interest of OUR PATIENT, not what's best for the surgeon...
Click to expand...

No kidding. How is not telling the surgeon what you are doing to give them the best optimal surgical conditions and keeping the patient safe unethical?
 
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IN reference to liver resections, i have before run a dense epidural with a phenylephrine ggt (my attending's decision). It brought CVP down to 1-2 and keep SBP up. Dont know of any study to support this particular method and what the risks of ARF post op are but we did loose less blood and with the negative data that continues to come out on blood transfusions who knows...

As far as the the general issue of intraoperative fluid replacement traditional methods for fluid replacment are being questioned by research. take for instance that data supports better outcomes for patients having outpt lap chole with larger volume resusitation ~30ml/kg per case. The opposite is true when looking at bowel surgery where the minimal fluid required seems to produce better outcomes. There was/is a great review article in the A&A IARS 2006 review course lectures by Prough and Sevensen "periopertive fluid management".

The question that often bothers me when doing a case where a surgeon requests low volume resusitation is whether the use of vasopressors is better than maintaining normovolemia in terms of postop organ dysfuntion. My gut tells me that vasopressors are not a better option, but once again who knows...
 
epidural man said:
No kidding. How is not telling the surgeon what you are doing to give them the best optimal surgical conditions and keeping the patient safe unethical?
Click to expand...

uhhhh, he's not "not telling," he's lying to the surgeon. and i assume also recording falsified data. = unethical
 
okay so the liver surgeons want low volume for their cases - but is that safe for the patient...

the answer is no (and this is based on a few near-deaths due to intra-op hemorrhage for livers)....

it is far easier to run some NTG to drop CVP and then turn it off and have tons of fluid reserves in play versus being several liters of fluid behind by the time the "merda" hits the fan

so use your tools and do what is safe for the patient ---

the good liver surgeons (ie: the ones who have had a lot of near death experiences) will eventually realize this and just request a low CVP - how you do that is up to you - and my money ain't on withholding fluid
 
gasnewby said:
so you just fudge it? that's ethical.
Click to expand...

Perhaps I just had the transducer off by 3 or 4 centimeters at the start of the case and I need to reassess this situation. It's hard to say.

Safe patient and happy surgeon is a reasonable goal.
 
epidural man said:
No kidding. How is not telling the surgeon what you are doing to give them the best optimal surgical conditions and keeping the patient safe unethical?
Click to expand...

i admit i've "given" a phantom dose of rocuronium here and there when an ortho resident says "what do you mean he has one twitch?? we need him paralyzed!" :rolleyes:

and i love it when 5 minutes later they say "he's loosening up, thanks."
 
how do you placate a crybaby. just do what they want (wink, wink :D).
 
Easy, when a surgeon asks you to change your anesthetic technique, ask him what suture he/she is going to use next. If they haven't gotten the hint and answer the question, then tell them that they should use some other ridiculous suture. Like plain gut. If they still haven't figured it out yet, just say "Thank You." Cause they will never get it.

To your ortho buddies, why tell them the twitch count? Too much information is a dangerous thing. I usually tell them the patient is paralyzed and it must be their technique. Smile and say it in a friendly way. You still questioned their manhood and they won't open themselves up to it again.
 
Well, we did a Left Hepatic Lobectomy last week on a 30 y/o with cholangiocarcinoma discovered after CT scan to evaluate IVC/SVC/Lungs for clot because he developed a second DVT while on coumadin. Starting HB 11.8 (dry) and INR 1.25. Has a history of idiopathic sinus tach and is on metoprolol.

I asked the surgeon if he wanted a CVP of 3-5. He said no. I lauded his desire for end organ perfusion.

PIV, R-IJ single lumen cordis (hospital out of double lumen which is what we wanted to place), a-line. 2 PRESSURE BAGS on IV POLES (note to people, these are VERY nice to have but are easily forgotten).

4U PRBC and 2 FFP upstairs. 2 More PRBC on hold downstairs.

About 3 hours into surgery the middle hepatic vein tears off the IVC. Prior to that I had the CVP 9, HR 70, BP 120/60. Buzzed attending while I started hanging blood and albumin while ordering more product.

Blood loss up to there was about 550 with HB of 10.3 on abg.

In about 5-8 minutes we lost 4.5 liters (70 kg dude...not cool). Bolusing neo slugs, 10 ucg bumps of epi, slamming in product. Gas off. Call for more emergency PRBC's.

Keeping up, keeping up, second suction is up and now the resident and ANOTHER attending surgeon are suctioning. Head surgeon is getting nervous now.

BP goes.......goes.......40/20. I'm starting to get full sympathetic blast from my own body. Stays there for about 10 seconds. Seemed like a day. Swung back up.

They got the bleeder.

So........anyways, that whole low CVP thing can kiss my a$$. A low CVP ain't gonna protect the patient from having a hole in his/her IVC. If we didn't have the reserve volume up front the guy would have been PEA for sure. We would have been running a code and that guy may not have made it. Or worse, he would have made it, but with a global hypoperfusion/cerebral anoxic injury. Not cool.
 
Sounds bad, I might consider tensma's earlier post as a means of lowering CVP. It also sounds like you were on game.
 
again

been there

done that

always keep the tank full on ANY case that involves the IVC --- unfortunately this is something the surgeons just DON'T understand

and run nitroglycerin infusion to keep the tension off the IVC...

and I disagree with those who feel like they have to "trick" the surgeons... that creates a very passive-aggressive relationship based on deceit...

if the surgeon asks for something I try to meet their needs as long as it doesn't interfere with the anesthetic or patient's physiology... if it is something that I disagree with then I tell them what I am thinking, what I am worried about and my suggestion on how to meet that need --- if they give me lip, then I ask them if they have any literature to support their bogus requests...

you guys shouldn't play the "phantom" drug game - because if something happens you will look like a lying idiot...

if ortho dude asks about paralysis I answer with a question: "How much more loose do you need the pt to be and how long do you require that amount of looseness and how much longer till you are done with the case?" then i make a decision based on those answers... I don't let them have a say on what anesthetic plan to commit to ... that is my decision...

it is ALL about communication - and watching the surgical field...
 
Tenesma said:
again

been there

done that

always keep the tank full on ANY case that involves the IVC --- unfortunately this is something the surgeons just DON'T understand

and run nitroglycerin infusion to keep the tension off the IVC...

and I disagree with those who feel like they have to "trick" the surgeons... that creates a very passive-aggressive relationship based on deceit...

if the surgeon asks for something I try to meet their needs as long as it doesn't interfere with the anesthetic or patient's physiology... if it is something that I disagree with then I tell them what I am thinking, what I am worried about and my suggestion on how to meet that need --- if they give me lip, then I ask them if they have any literature to support their bogus requests...

you guys shouldn't play the "phantom" drug game - because if something happens you will look like a lying idiot...

if ortho dude asks about paralysis I answer with a question: "How much more loose do you need the pt to be and how long do you require that amount of looseness and how much longer till you are done with the case?" then i make a decision based on those answers... I don't let them have a say on what anesthetic plan to commit to ... that is my decision...

it is ALL about communication - and watching the surgical field...
Click to expand...

For those that DO request a lower CVP I'll keep the tank plenty full and run a touch of NTG.

Thanks for the tip homey.
 
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