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Coeckelenbergh S, Desebbe O, Carrier FM, Thepault F, De Oliveira C, Pellerin F, Le Canne C, Herboulier L, Laukaityte E, Moussa M, Toubal L, Kato H, Pham H, Roullet S, Lanteri Minet M, Amara Y, Naili S, Ciacio O, Cherqui D, Duranteau J, Vincent JL, Van der Linden P, Joosten A. Intraoperative measurement of the respiratory exchange ratio predicts postoperative complications after liver transplantation. BMC Anesthesiol 2022; 22:405. [PMID: 36577954 PMCID: PMC9795787 DOI: 10.1186/s12871-022-01949-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND During surgery, any mismatch between oxygen delivery (DO2) and consumption (VO2) can promote the development of postoperative complications. The respiratory exchange ratio (RER), defined as the ratio of carbon dioxide (CO2) production (VCO2) to VO2, may be a useful noninvasive tool for detecting inadequate DO2. The primary objective of this study was to test the hypothesis that RER measured during liver transplantation may predict postoperative morbidity. Secondary objectives were to assess the ability of other variables used to assess the DO2/VO2 relationship, including arterial lactate, mixed venous oxygen saturation, and veno-arterial difference in the partial pressure of carbon dioxide (VAPCO2gap), to predict postoperative complications. METHODS This retrospective study included consecutive adult patients who underwent liver transplantation for end stage liver disease from June 27th, 2020, to September 5th, 2021. Patients with acute liver failure were excluded. All patients were routinely equipped with a pulmonary artery catheter. The primary analysis was a receiver operating characteristic (ROC) curve constructed to investigate the discriminative ability of the mean RER measured during surgery to predict postoperative complications. RER was calculated at five standardized time points during the surgery, at the same time as measurement of blood lactate levels and arterial and mixed venous blood gases, which were compared as a secondary analysis. RESULTS Of the 115 patients included, 57 developed at least one postoperative complication. The mean RER (median [25-75] percentiles) during surgery was significantly higher in patients with complications than in those without (1.04[0.96-1.12] vs 0.88[0.84-0.94]; p < 0.001). The area under the ROC curve was 0.87 (95%CI: 0.80-0.93; p < 0.001) with a RER value (Youden index) of 0.92 giving a sensitivity of 91% and a specificity of 74% for predicting the occurrence of postoperative complications. The RER outperformed all other measured variables assessing the DO2/VO2 relationship (arterial lactate, SvO2, and VAPCO2gap) in predicting postoperative complications. CONCLUSION During liver transplantation, the RER can reliably predict postoperative complications. Implementing this measure intraoperatively may provide a warning for physicians of impending complications and justify more aggressive optimization of oxygen delivery. Further studies are required to determine whether correcting the RER is feasible and could reduce the incidence of complications.
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Affiliation(s)
- Sean Coeckelenbergh
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France ,grid.512286.aOutcomes Research Consortium, Cleveland, OH USA
| | - Olivier Desebbe
- Department of Anesthesiology and Perioperative Medicine Sauvegarde Clinic, Ramsay Santé, Lyon, France
| | - François Martin Carrier
- grid.410559.c0000 0001 0743 2111Department of Anesthesiology and Department of Medicine, Critical Care Division, Centre hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Francois Thepault
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Cécile De Oliveira
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Florian Pellerin
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Cyril Le Canne
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Laurence Herboulier
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Edita Laukaityte
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Maya Moussa
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Leila Toubal
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Hiromi Kato
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Hung Pham
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Stephanie Roullet
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Marc Lanteri Minet
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Youssef Amara
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Salima Naili
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Oriana Ciacio
- grid.413133.70000 0001 0206 8146Department of Liver Hepatobiliary Surgery & Liver Transplantation, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Daniel Cherqui
- grid.413133.70000 0001 0206 8146Department of Liver Hepatobiliary Surgery & Liver Transplantation, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Jacques Duranteau
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Alexandre Joosten
- grid.413133.70000 0001 0206 8146Department of Anesthesiology and Intensive Care, Paul Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
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Comparison of central and mixed venous saturation during liver transplantation in cirrhotic patients: a pilot study. Eur J Anaesthesiol 2011; 27:714-9. [PMID: 20308906 DOI: 10.1097/eja.0b013e328335b33a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Liver transplantation is associated with important haemodynamic variations requiring cardiac output and oximetric data monitoring. The mixed venous saturation (SvO2) integrates parameters combining information about oxygen consumption, cardiac output and haemoglobin concentration. Central venous saturation (ScvO2) can be directly measured from blood drawn in the superior venous system via a central venous catheter. ScvO2 has been proposed as an alternative to SvO2 for intraoperative haemodynamic monitoring. The aim of the present study was to examine the level of agreement between SvO2 and ScvO2 during the preanhepatic and the neohepatic stage of liver transplantation in cirrhotic patients. MATERIALS AND METHODS After agreement from the regulatory authorities for medical research and having obtained informed consent, 30 patients with cirrhosis undergoing liver transplantation were prospectively included. Blood gas samples were simultaneously drawn from the arterial line, the right atrium port and the pulmonary artery port of the catheter: during the preanhepatic stage (two times) and two times 30-40 min after graft revascularization. Arterial saturation (SaO2), haemoglobin concentration, cardiac index, SvO2, ScvO2 and oxygen consumption, delivery and extraction (VO2, DO2 and EO2, respectively) were measured. A Bland-Altman test was used to determine bias and limits of agreement between SvO2 and ScvO2. Both parameters were considered to be equivalent if limits of agreement were within +/-5%. RESULTS Bland-Altman analysis revealed a bias (limit of agreement) of -1.2% (-9.1 to 6.6%), -0.3% (-4.8 to 4%) and -2.1% (-12 to 7.8%) for the overall measurements and preanhepatic and postgraft reperfusion measurements, respectively. SvO2 decreased significantly between hepatectomy and reperfusion, whereas cardiac index, VO2, DO2 and EO2 showed significantly higher values after reperfusion. ScvO2 and SaO2 levels did not display different values between the two periods. DISCUSSION Measurements of SvO2 and ScvO2 showed a good level of agreement during the preanhepatic stage, whereas the level of agreement was low after liver graft reperfusion. The increase of VO2 associated with the decrease of SvO2 and the stability of ScvO2 between the two periods suggest an incomplete mixing of splanchnic venous blood into the right atrium. In addition, our samples were taken from the right atrium, which is not possible using a conventional central venous catheter, as the tip must lie in the superior vena cava and not in the right atrium. ScvO2 cannot be considered equivalent to SvO2 for the haemodynamic monitoring of patients with cirrhosis undergoing liver transplantation.
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Kostopanagiotou G, Theodoraki K, Pandazi A, Arkadopoulos N, Kostopanagiotou K, Smyrniotis V. Changes in oxyhemoglobin dissociation curve in intrabdominal organs during pig experimental orthotopic liver transplantation. Liver Transpl 2005; 11:760-766. [PMID: 15973719 DOI: 10.1002/lt.20438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Liver transplantation has become a gold standard treatment for irreversible liver disease. Conventional measures of oxygenation are inadequate to understand the dynamics of regional oxygen metabolism during liver transplantation because they represent global markers of tissue dysoxia. Therefore, the addition of an assessment of the hemoglobin O(2) binding capacity can give a better insight into systemic and regional tissue oxygenation and can reflect a more accurate estimation of oxygen release to the tissues than can the hemoglobin, the PaO(2) and SaO(2) alone. This prospective study was designed to evaluate possible alterations in the oxyhemoglobin dissociation curve of vital end organs (small bowel, liver, and kidney) in an experimental liver transplantation model. Fifteen pigs with body weights ranging from 25 to 30 kg were used for the study. Five healthy pigs underwent a sham operation under general anesthesia (group A-control). Ten pigs underwent orthotopic liver transplantation (OLT). Five of them were healthy (group B), whereas the other five were in acute liver failure, which had been surgically induced (group C). Systemic arterial blood pressure, cardiac index, and pulmonary and systemic vascular resistance indexes were measured. Venous blood gas analysis was also performed from pulmonary artery, superior mesenteric, hepatic, and renal veins at well-defined timepoints during the course of the OLT. A statistically significant (P < 0.05) decrease of P(50) in groups B and C compared with group A was observed 30 minutes after reperfusion in the systemic circulation, hepatic, and renal veins. This coincided with a decrease in animal temperature 30 minutes after reperfusion. Regarding group C, after reperfusion of the newly transplanted liver there was a significant increase of P(50) in the small bowel in comparison to baseline values. In conclusion, these changes in P(50) may suggest the occurrence of abnormal tissue oxygenation after reperfusion.
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Affiliation(s)
- Georgia Kostopanagiotou
- Second Department of Anesthesiology, Attikon Hospital, University of Athens School of Medicine; Athens, Greece
| | - Kassiani Theodoraki
- First Department of Anesthesiology, Aretaieion Hospital, University of Athens School of Medicine, Athens, Greece
| | - Ageliki Pandazi
- Second Department of Anesthesiology, Attikon Hospital, University of Athens School of Medicine; Athens, Greece
| | - Nikolaos Arkadopoulos
- Second Department of Surgery, Aretaieion Hospital, University of Athens School of Medicine, Athens, Greece
| | | | - Vassilios Smyrniotis
- Second Department of Surgery, Aretaieion Hospital, University of Athens School of Medicine, Athens, Greece
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Epstein SK, Freeman RB, Khayat A, Unterborn JN, Pratt DS, Kaplan MM. Aerobic capacity is associated with 100-day outcome after hepatic transplantation. Liver Transpl 2004; 10:418-24. [PMID: 15004771 DOI: 10.1002/lt.20088] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The shortage of donor organs highlights the need to better identify patients most likely to benefit from hepatic transplantation. Reduced aerobic capacity (decreased peak oxygen consumption [VO(2)] during symptom-limited cardiopulmonary exercise testing) is frequently present in cirrhosis. Peak VO(2) during cardiopulmonary exercise testing may predict short-term outcome after hepatic transplantation. Symptom-limited testing was performed on a cycle ergometer (continuous ramp protocol) and VO(2) determined using a metabolic cart. One hundred fifty-six patients were tested; 59 subsequently underwent hepatic transplantation. Results showed that survivors and nonsurvivors were similar in age, duration of liver disease, Child-Pugh score, MELD score, resting cardiovascular function, pulmonary function, and gas exchange. The 6 (10.2%) patients dying within 100 days of transplantation were more likely to have reduced aerobic capacity (peak VO(2) <60% predicted and VO(2) at anaerobic threshold [VO(2)-AT] <50% predicted peak VO(2)) compared to survivors (4/6 vs. 7/53, P <.01). Using a multiple logistic regression model controlling for duration and severity of liver disease and time to transplantation, reduced aerobic capacity was independently associated with 100-day mortality. In conclusion, reduced aerobic capacity during cardiopulmonary exercise testing is associated with decreased short-term survival after hepatic transplantation. Further study is needed to determine if cardiopulmonary exercise testing can be used to improve allocation of donor organs. To ensure optimum allocation of donor organs, it is important to identify patients most likely to benefit from transplantation. Investigators have identified a number of preoperative, intraoperative, and postoperative factors that predict increased risk for postoperative mortality. Unfortunately, predictive accuracy has not been high, and the timing of factor identification does not optimize organ utilization. Identification of predictors of survival at the time of listing for transplantation might lead to better resource allocation.
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Affiliation(s)
- Scott K Epstein
- Department of Medicine, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
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