Effects of the Hypnotic Agent on Primary Graft Dysfunction After Liver Transplantation

Comparison of total intravenous anesthesia and inhalational anesthesia in patients undergoing liver surgery: a systematic review and meta-analysis

BACKGROUND

The impact of choosing between inhalational anesthetics and propofol for maintenance anesthesia in liver transplantation or liver resections remains uncertain.

METHODS

A systematic search was conducted on PubMed, Scopus, Embase, Web of Science, and the Cochrane Library on September 5, 2023, adhering to the Cochrane Handbook and PRISMA guidelines.

RESULTS

Fifteen randomized controlled trials and five observational studies, comprising 1,602 patients, were included. The statistical analysis was categorized into three groups: liver transplantation (four studies), living donor hepatectomy (four studies), and liver mass hepatectomy (twelve studies). The liver mass hepatectomy group was further subdivided based on the performance of the Pringle maneuver and the use of pharmacological preconditioning. Statistically significant results are described below. In liver transplant recipients, propofol anesthesia was associated with lower AST levels on the first postoperative day. Hepatic donors anesthetized with propofol had higher total infusion volumes and intraoperative urine output. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher peak AST and ALT levels compared to those who received pharmacological preconditioning. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher AST and ALT levels on both the first and third postoperative days, increased total infusion volumes, and shorter hospital stays, when compared to pharmacological conditioning.

CONCLUSIONS

Our findings do not offer sufficient evidence to inform clinical practice. The choice between propofol-based and inhalational anesthesia should be tailored to the individual patient's condition and the nature of the procedure being performed.

REGISTRATION

PROSPERO ID: CRD42023460715.

The Effects of Volatile Anesthetics on Early Clinical Outcomes in Liver Transplantation: A Systematic Review and Meta-Analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to evaluate the effects of volatile anesthesia (VA) on early clinical outcomes in liver transplantation.

METHODS

We searched electronic databases to identify relevant studies comparing VA to non-VA in liver transplant recipients. The primary outcome assessed was early allograft dysfunction (EAD), and secondary outcomes were postoperative peak liver function tests (LFT) including aspartate transaminase (AST) and alanine transaminase (ALT) levels, and hospitalization time.

RESULTS

Six relevant studies involving 919 patients were analyzed. In meta-analysis of prospective studies, VA was associated with fewer incidence of EAD than non-VA (RR: 0.45; 95% CI: 0.25, 0.84; P = .012; I2 = 0%; Ph = 0.334) but this association was not significant in meta-analysis of retrospective studies (OR: 0.83; 95% CI: 0.58, 1.19; P = .310; I2 = 0%; Ph = 0.624). No significant difference in peak AST (SMD: -0.14 U/L; 95% CI: -0.65, 0.37 U/L; P = .594; I2 = 69.9%; Ph = 0.036) and ALT (SMD: -0.16 U/L; 95% CI: -0.65, 0.33 U/L; P = .529; I2 = 67.0%; Ph = 0.048) were found between VA and non-VA. The hospitalization time also did not differ between the two groups (SMD: -0.09 days; 95% CI: -0.29, 0.10 days; P = .350; I2 = 0%; Ph = 0.864).

CONCLUSIONS

While there is potential protective effect of VA against EAD in liver transplant recipients, certainty remains low, whereas VA was not associated with postoperative LFT or hospitalization time.

Sevoflurane preconditioning in living liver donation is associated with better initial graft function after pediatric transplantation: a retrospective study

INTRODUCTION

Initial allograft function determines the patient's immediate prognosis in pediatric liver transplantation. Ischemia-reperfusion injuries play a role in initial poor graft function (IPGF). In animal studies, preconditioning with inhaled anesthetic agents has demonstrated a protective effect on the liver. In humans, the few available studies are conflicting. This study assesses the association between the hypnotic agent used to maintain anesthesia during hepatectomy in living donors and the occurrence of IPGF after pediatric transplantation.

METHODS

We conducted a single-center retrospective analysis of children who received a living donor liver transplant (LDLT) between 2010 and 2019. We analyzed the incidence of EAD according to the hypnotic agent used to maintain general anesthesia during donor hepatectomy.

RESULTS

We included 183 pairs of patients (living donors-recipients). The anesthetics used in the donor were propofol (n = 85), sevoflurane (n = 69), or propofol with sevoflurane started 30 min before clamping (n = 29). Forty-two children (23%) developed IPGF. After multivariate logistic regression analysis, factors significantly associated with the occurrence of IPGF were the anesthesia maintenance agent used in the donor (p = 0.004), age of the donor (p = 0.03), duration of transplant surgery (p = 0.009), preoperative receiver neutrophil to lymphocyte ratio (p = 0.02), and albumin (p = 0.05).

CONCLUSION

Significantly fewer children who received a graft from a donor in whom only sevoflurane was used to maintain anesthesia developed IPGF. Although additional research is needed, this preconditioning strategy may provide an option to prevent IPGF after living liver donation.

Anesthesia Management of a Liver Transplant Recipient with Remimazolam

Background

Intraoperative anesthetic requirements might be altered due to the modulated metabolic function in living donor liver transplant recipients. Remimazolam may provide appropriate anesthesia in patients with cirrhosis. However, the efficacy and safety of remimazolam in liver transplant recipients have not been reported. We present the successful anesthesia management of a liver transplant recipient using remimazolam. Case Presentation. A 54-year-old woman who was diagnosed with Child-Pugh C cirrhosis of unknown etiology was scheduled for living donor liver transplantation. Remimazolam was used for anesthesia management under electroencephalogram monitoring, including bispectral index (BIS) and patient state index (PSI) values. Despite the prolonged surgical time (1,037 min) and massive blood loss (22,500 mL), BIS and PSI values were maintained within acceptable ranges intraoperatively. There was no intraoperative awareness/recall or adverse events associated with remimazolam administered perioperatively.

Conclusions

We safely managed general anesthesia for living donor liver transplantation with remimazolam using electroencephalogram monitoring.

Optimal anesthetic conduct regarding immediate and short-term outcomes after liver transplantation - Systematic review of the literature and expert panel recommendations

BACKGROUND

In the era of enhanced recovery after surgery, there is significant discussion regarding the impact of intraoperative anesthetic management on short-term outcomes following liver transplantation (LT), with no clear consensus in the literature.

OBJECTIVES

To identify whether or not intraoperative anesthetic management affects short-term outcomes after liver transplantation.

DATA SOURCES

Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.

METHODS

A systematic review following PRISMA guidelines was undertaken. The systematic review was registered on PROSPERO (CRD42021239758). An international expert panel made recommendations for clinical practice using the GRADE approach.

RESULTS

After screening, 14 studies were eligible for inclusion in this systematic review. Six were prospective randomized clinical trials, three were prospective nonrandomized clinical trials, and five were retrospective studies. These manuscripts were reviewed to look at five questions regarding anesthetic care and its impact on short term outcomes following liver transplant. After review of the literature, the quality of evidence according to the following outcomes was as follows: intraoperative and postoperative morbidity and mortality (low), early allograft dysfunction (low), and hospital and ICU length of stay (moderate).

CONCLUSIONS

For optimal short term outcomes after liver transplantation, the panel recommends the use of volatile anesthetics in preference to total intravenous anesthesia (TIVA) (Level of Evidence: Very low; Strength of Recommendation: Weak) and minimum alveolar concentration (MAC) versus bispectral index (BIS) for depth of anesthesia monitoring (Level of Evidence: Very low; Strength of Recommendation: Weak). Regarding ventilation and oxygenation, the panel recommends a restrictive oxygenation strategy targeting a PaO₂ of 70-120 mmHg (10-14 kPa), a tidal volume of 6-8 ml/kg ideal body weight (IBW), administration of positive end expiratory pressure (PEEP) tailored to patient intraoperative physiology, and recruitment maneuvers. (Level of evidence: Very low; Strength of Recommendation: Strong). Finally, the panel recommends the routine use of antiemetic prophylaxis. (Level of evidence: low; Strength of Recommendation: Strong).

Influence of anesthesia type on post-reperfusion syndrome during liver transplantation: a single-center retrospective study

Background

Post-reperfusion syndrome (PRS) results in sudden hemodynamic instability following graft reperfusion. Although PRS is known to influence outcomes following liver transplantation, little is known regarding the effects of anesthetics on PRS. This study investigated the association between the type of anesthetic agent and PRS in liver transplantation.

Methods

This single-center retrospective cohort study included patients who underwent liver transplantation between June 2016 and December 2019. Patients were divided into sevoflurane and propofol groups according to the anesthetic agent used. Stabilized inverse probability of treatment weighting (IPTW) analysis was performed to investigate the association between PRS identified based on blood pressure recordings and the type of anesthesia. Associations between the anesthetic agent and the duration of hypotension as well as early postoperative outcomes were also investigated.

Results

Data were analyzed for 398 patients, 304 (76.4%) and 94 (23.6%) of whom were anesthetized with propofol and sevoflurane, respectively. PRS developed in 40.7% of the 398 patients. Following stabilized IPTW analysis, the association with PRS was lower in the sevoflurane group than in the propofol group (odds ratio, 0.47; P = 0.018). However, there was no association between the type of anesthetic used and early postoperative outcomes.

Conclusions

The association of PRS was lower in the sevoflurane group than in the propofol group. However, there was no association between the type of anesthetic and the early postoperative outcomes. Further studies are required to determine the optimal anesthetic for liver transplantation.

Primary liver graft dysfunction and non-function: integrative literature review

Avoiding deaths in the waiting list for an organ is no longer the only focus of the transplant teams attention. Research and care in clinical practice has been increasingly focused on post transplant graft survival and functioning. In the present work, we performed an integrative literature review to identify the terminology used about liver graft dysfunction and non-function, as well as to investigate the incidence and risk factors of these clinical events. We chosen articles written in Portuguese, English and Spanish between 2012 and 2016, based on CINAHL, MEDLINE, Cochrane, LILACS, BDENF, IBECS, EMBASE and Web of Science. We selected 14 studies, in which we identified the incidence of hepatic graft dysfunction ranging from 7% to 27%. The terminology used to describe this clinical event was initial malfunction, graft hypofunction, marginal function or delay in function. The primary non-function of the liver graft was found in 1.4% to 8.4% of the patients, and the terminology used to describe the event was early dysfunction or graft loss. The risk factors found are related to donor, recipient, graft and transplant logistics variables. We conclude that knowledge of the different terminologies employed in the literature, related to dysfunction and primary non- function incidence, and of their risk factors are fundamental to qualify the control of the events, aiming to improve patients' survival after liver transplantation.

Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery

As solid organ transplantation increases and patient survival improves, it will become more common for these patients to present for nontransplant surgery. Recipients may present with medical problems unique to the transplant, and important considerations are necessary to keep the transplanted organ functioning. A comprehensive preoperative examination with specific focus on graft functioning is required, and the anesthesiologist needs pay close attention to considerations of immunosuppressive regimens, blood product administration, and the risk benefits of invasive monitoring in these immunosuppressed patients. This article reviews the posttransplant physiology and anesthetic considerations for patients after solid organ transplantation.