Optimization of Anesthesia and Critical Care during Major Liver Resections

V.I. Cherniy, K.A. Kolganova, M.V. Freigofer

Abstract


Background. Anesthetic management of liver resections in oncosurgery still remains a major problem in modern medicine. These operations are traumatizing and cause massive nociceptive stimulation, intraoperative bleeding, total hypothermia, which can lead to hemodynamic instability, cardiac ischemia, immune, respiratory and thromboembolic complications. The problem of choosing anesthetic technique for liver resections and evaluation of anesthesia adequacy remain a disputable issue. The development of effective blood-saving schemеs and thromboprophylaxis during major liver resection require further study. The aim of the work was to improve the efficiency of anesthesia and perioperative intensive care during major liver resections in cases of tumors. Materials and methods. 121 patients undergoing liver resections were included in the clinical research. All patients were divided into 3 groups depending on the methods of anesthesia, infusion-transfusion therapy and postoperative analgesia. Groups were matched for age, sex, diagnosis, anthropometric indicators, nature and duration of the operative intervention. The scheme of the total intravenous anesthesia with propofol, fentanyl and morphine for postoperative analgesia has been used in the first group of patients (n = 41). The scheme of the total intravenous anesthesia with propofol, fentanyl and prolonged epidural bupivacaine analgesia has been used in the second group of patients (n = 40). The scheme of inhalation sevofluran anesthesia with prolonged epidural bupivacaine analgesia has been used in the third group of patients (n = 40). The standard method of infusion with donor blood has been used in patients of the control group (n = 41). The method of autohemotransfusion and normovolemic hemodilution has been used in patients of the second and the third (study) groups (n = 80). Thromboprophylaxis with anticoagulants (bemiparin and enoxaparin) began the day before liver resection and lasted for 10–14 days. The comparative analysis of the efficacy and safety of described schemes has been made for important indicators of hemodynamic, cardiac rhythm variability, serum cortisol concentration, glycemia, hemogram and coagulation, bleeding and thrombotic complications incidence, serum concentrations of activated anti-X factor of coagulation, clinical indicators of postoperative recovery period. Results. Initial parameters of central hemodynamics, heart rate variability, glycemia, cortisol serum concentration, hemogram were not statistically different in all three groups. Parameters of mean arterial pressure, heart rate and total peripheral vessels resistance have been increased in the first group. Tonus of sympathetic nervous system was lower in patients of the second and the third groups than in the first group according to heart rate variability. The hyperglycemia has been registered in patients of the first group at all stages of treatment. Maximum serum cortisol concentration was registered in the group 1, which indicates adrenal hormone hyperproduction associated with low adequacy of total intravenous anesthesia. Intermediate cortisol value was found in group 2, and minimum cortisol value was found in group 3. Postoperative pain was more disturbing in patients of group 1 than in the 2nd and the 3rd groups during first three days after surgery. The level of sedation was statistically significantly lower in the groups of epidural analgesia than in the group of opioids. Hemoglobin, erythrocytes and hematocrit levels were significantly higher after surgery in the study group than the same levels in the control group, which reduced the need of donor blood transfusion. The use of anticoagulants in clinically significant cases has reported neither thrombosis nor bleeding tissue, and massive bleeding was registered in 9 patients (5 from the 1st group (11 %) and 4 from the 2nd group (5 %)) due to the specifics of surgical hemostasis. The level of activated in anti-X factor coagulation required thromboprophylaxis was achieved after the first injection and persisted throughout the postoperative period. Obtained laboratory results indicate that preoperative autoblood preparation according to the described method is secure from the viewpoint of saving oxygen-transport function and its hemostatic potential. The research has proved a positive influence of preemptive analgesia and combined epidural anesthesia on the course of rehabilitation period by decreasing prolonged artificial pulmonary ventilation duration, time before tracheal extubation, post-surgery pain and sedation intensity, early enteral feeding introduction, respiratory and infectious complication incidence after liver resection, length of a patient’s stay in intensive care unit and hospital stay duration. Conclusions. The developed scheme of combined anesthesia with epidural analgesia, autohemotransfusion, normovolemic hemodilution and anticoagulant thromboprophylaxis provides high hemodynamic stability, neurovegetative protection, reduces incidence of bleeding, helps to reduce the need for blood products transfusion, provides more effective thromboembolic prophylaxis without increasing hemorrhagic risks and facilitates rehabilitation period.

Keywords


liver resection; epidural anaesthesia; evaluation of adequacy; critical care

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DOI: https://doi.org/10.22141/2224-0586.7.78.2016.86094

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