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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


TED Assuit