Khaled Yassen MD FFARCSI Professor of Anaesthesia Liver Institute, Menoufiya University, Egypt. kyassen61@hotmail.com
Research Team Hanaa Said MBBcH
Osama El Sharkawy, MD Emad Refaat, MD Abdel Elmoniem Ibraheem, MD Wafiya Mahdy, MD
Nirmeen Fayed, MD
Ethics No conflict of Interest
MSC Thesis from Menoufiya University, Egypt Ethics committee approval by both Faculty of Medicine, Menoufiya University and Liver Institute, Menoufiya University, Egypt Presented at European Society Meeting , Paris, June 2012 as a poster presentation.
Paris Transesophageal doppler as a haemodynamic monitor during and after liver resection for cirrhotic patients. An observational study Yassen K., El Sharkawy O., Ibraheem A.E., Refaat E., Mahdy W., Fayed N. Liver Institute Menoufiya University, Department of Anaesthesiology and Intensive Care, Sheeben El Kom, Egypt Poster presentation
Introduction
ď‚— Liver resection is usually associated with
dramatic haemodynamic changes
ď‚— The non invasive methods are usually
preferable
ď‚— Transesophageal doppler (TED) is one of
the recently intoduced minimally invasive methods for haemodynamic monitoring.
Transesophageal Doppler (TED) 1- Provides a continuous beat to beat waveform that is proportional to the left ventricular stroke volume.
2-Derives haemodynamic variables that may guide clinical management.
3- With each heart beat, the velocity of blood Flowing through the descending aorta detected
and
depicted as a velocity over time wave form.
ď‚— Haemodynamic monitoring
ď‚— Intraoperative fluid balance optimization
using TED versus central venous pressure .
ď‚— follow up the postoperative complications
and hospital stay in these patients.
Methodology Patients population 39 Child A cirrhotic patients undergoing right lobe resection.
-Exclusion Criteria : 1) severe coagulopathy 2)Esophageal pathology 3)Coarctation of the aorta 4)Unstable haemodynamics
Anaesthetic Management Premedication, Routine monitoring. General anaesthesia
Mechanical ventilation, Normothermia. Insertion of esophageal doppler probe.
Normal wave form
Abnormal traces
Intra-cardiac trace.
Venous trace.
Coeliac artery trace
Pulmonary artery trace
Algorithm for fluid administration
British Journal of Hospital Medicine, 2007
Measurments 1)Haemodynamic parameters 2)TED parameters 3)Other parameters Data were recorded at five points ; T1- After induction of anesthesia T2-Laparotomy: - after the abdominal fascia opening. T3-Hepatectomy phase T4- At the end of surgery T5-24 hours after surgery
Demographic data
HR (beat/min) 120
110
110
100
100
90
90
80
70
80
60
70 50
60 T1
T1
T2
T3
T4
T2
T3
T4
T5
T5
Heart rate changes in Doppler group.
Heart rate changes in Control group.
Changes over time were statistically
Changes
significant, P- < 0.05.
significant, P- < 0.05.
over
time
were
statistically
MBP (mmHg(
125
120
110 100
100 75
90 50
80
25
70
60
0 T1
T2
T3
T4
T5
Mean blood pressure changes in Doppler group. Changes allover time statistically significant Pvalue < 0.05
T1
T2
T3
T4
T5
Mean blood pressure changes in Control group.
Changes allover time statistically significant
P-value < 0.05
CVP (cmH2O( 15.0
14
12
12.5 10
10.0 8
6
7.5
4
5.0 2
2.5 0
T1 T1
T2
T3
T4
T2
T3
T4
T5
T5
central venous pressure changes in Doppler
central venous pressure changes in Control
group. changes were insignificant, P-
group. changes were insignificant, P-value >
value > 0.05
0.05
SV(ml/beat) 140
120
100
80
60
40 T1
T2
T3
T4
Stroke volume changes in Doppler group . Changes allover time statistically significant, P-value < 0.05.
T5
COP changes(l/min) 12
10
8
6
4
2 T1
T2
T3
T4
T5
Cardiac out put changes in Doppler group . Changes allover time statistically significant, P-value < 0.05.
CI(L/min/m2) 7
6
5
4
3
2
1 T1
T2
T3
T4
T5
Cardiac index changes in Doppler group . Changes allover time statistically significant, P-value < 0.05.
SVR (dyne.sec/cm-5) 2,500
2,000
1,500
1,000
500
0 T1
T2
T3
T4
T5
SVR changes in Doppler group . Changes allover time statistically significant, P-value < 0.05.
FTc (msec( 500
400
300
200
100 T1
T2
T3
T4
T5
Corrected flow time changes in Doppler group . Changes allover time statistically insignificant, P-value > 0.05.
*
P value <0.05
No correlation between FTc and CVP P > 0.05
Postoperative complications and hospital stay 8
*
7
6 5 4 Hospital stay
3 2
1 0
10 9 8 7 6 5 4 3 2 1 0
* PONV Chest infection
Doppler Doppler
Control
*
P value <0.05
Control
ď&#x201A;&#x2014;
TED was able to: 1- Detect Significant increase in COP, CI and SV immediately after liver resection 2- Significant reduction in SVR after liver resection and during the early postoperative period. 3-Optimize intraoperative fluid consumption. 4- Decrease postoperative complication and shortened the hospital stay.
5-Minimal skills were needed for insertion and interpretation, no reported complications from the process of monitoring.
6-The current algorithm failed to lower CVP to below 5 cmH2O during resection phase.
1- Haemodynamic monitoring during liver resection is essential. 2-Optimization of intraoperative fluid 3-TED is a valuable tool for intraoperative monitoring 4-A future larger study to adjust the rate of fluid administration is needed in such category of patients and to study CVP and FTc relationship.
Thank You