Current application status of low central venous pressure in hepatectomy_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

XU Zhao , YU Hong ,  LIANG Peng

Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, P. R. China;

Corresponding author：

LIANG Peng, Email: liangpeng_world@foxmail.com

Keywords：

hepatectomy; low ventral venous pressure; prognosis

DOI：

10.7507/1007-9424.201905052

Video：

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Objective To investigate various methods and strategies of lowering central venous pressure (CVP) during hepatectomy.Method Through literature review, the definition, implementation, related complications, and prognosis of low CVP were reviewed and summarized and the most appropriate CVP in the liver surgery was also summarized.Results The low CVP had been widely applied in the different clinical settings. Its effect of reducing hemorrhage and transfusion had been recognized. There were many techniques to intraoperatively reduce the CVP such as the volatile anesthetics, vasoactive agents, fluid restrictive strategy, inferior vena cava clamping, low tidal volume, etc. However, there was no consensus on the best strategy to reduce the CVP and there were no studies focusing on the prognosis of patients underwent the low CVP hepatectomy. Maintaining the CVP between 2.1–3 mm Hg (1 mm Hg=0.133 kPa) intraoperatively might be appropriate, once the section had been made normal hemodynamic state of the patient should be restored immediately.Conclusions Application of low CVP could reduce blood loss and transfusion in hepatectomy. Prognosis of patients receiving low CVP is not clear. Application of low CVP in specific population should be cautious.

Citation： XU Zhao, YU Hong, LIANG Peng. Current application status of low central venous pressure in hepatectomy. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2020, 27(1): 107-112. doi: 10.7507/1007-9424.201905052 Copy

1.	Mullen JT, Ribero D, Reddy SK, et al. Hepatic insufficiency and mortality in 1 059 noncirrhotic patients undergoing major hepatectomy. J Am Coll Surg, 2007, 204(5): 854-862.
2.	Bui LL, Smith AJ, Bercovici M, et al. Minimising blood loss and transfusion requirements in hepatic resection. HPB (Oxford), 2002, 4(1): 5-10.
3.	McNally SJ, Revie EJ, Massie LJ, et al. Factors in perioperative care that determine blood loss in liver surgery. HPB (Oxford), 2012, 14(4): 236-241.
4.	Combeer EL, Quiney NF, Karanjia ND, et al. A risk score for predicting perioperative blood transfusion in liver surgery (Br J Surg 2007; 94: 860-865). Br J Surg, 2007, 94(12): 1574.
5.	Lucas DJ, Schexneider KI, Weiss M, et al. Trends and risk factors for transfusion in hepatopancreatobiliary surgery. J Gastrointest Surg, 2014, 18(4): 719-728.
6.	Freedman J, Luke K, Escobar M, et al. Experience of a network of transfusion coordinators for blood conservation (Ontario Transfusion Coordinators [ONTraC]). Transfusion, 2008, 48(2): 237-250.
7.	Shander A, Hofmann A, Ozawa S, et al. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion, 2010, 50(4): 753-765.
8.	Katz SC, Shia J, Liau KH, et al. Operative blood loss independently predicts recurrence and survival after resection of hepatocellular carcinoma. Ann Surg, 2009, 249(4): 617-623.
9.	Cannon RM, Brown RE, St Hill CR, et al. Negative effects of transfused blood components after hepatectomy for metastatic colorectal cancer. Am Surg, 2013, 79(1): 35-39.
10.	Correa-Gallego C, Gonen M, Fischer M, et al. Perioperative complications influence recurrence and survival after resection of hepatic colorectal metastases. Ann Surg Oncol, 2013, 20(8): 2477-2484.
11.	Hill GE, Frawley WH, Griffith KE, et al. Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma, 2003, 54(5): 908-914.
12.	Hallet J, Tsang M, Cheng ES, et al. The impact of perioperative red blood cell transfusions on long-term outcomes after hepatectomy for colorectal liver metastases. Ann Surg Oncol, 2015, 22(12): 4038-4045.
13.	Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev, 2006, (1): CD005033.
14.	Rees M, Plant G, Wells J, et al. One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery. Br J Surg, 1996, 83(11): 1526-1529.
15.	Melendez JA, Arslan V, Fischer ME, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of post-operative renal dysfunction. J Am Coll Surg, 1998, 187(6): 620-625.
16.	El-Kharboutly WS, El-Wahab MA. The role of adoption of low central venous pressure in hepatic resection with pringle manoeuvre in reducing blood loss and improving operative outcome. Egyptian J Anaesth, 2004, 20(4): 369-376.
17.	Kato M, Kubota K, Kita J, et al. Effect of infra-hepatic inferior vena cava clamping on bleeding during hepatic dissection: a prospective, randomized, controlled study. World J Surg, 2008, 32(6): 1082-1087.
18.	Rahbari NN, Koch M, Zimmermann JB, et al. Infrahepatic inferior vena cava clamping for reduction of central venous pressure and blood loss during hepatic resection: a randomized controlled trial. Ann Surg, 2011, 253(6): 1102-1110.
19.	Wang WD, Liang LJ, Huang XQ, et al. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol, 2006, 12(6): 935-939.
20.	Zhu P, Lau WY, Chen YF, et al. Randomized clinical trial comparing infrahepatic inferior vena cava clamping with low central venous pressure in complex liver resections involving the Pringle manoeuvre. Br J Surg, 2012, 99(6): 781-788.
21.	Cheng ES, Hallet J, Hanna SS, et al. Is central venous pressure still relevant in the contemporary era of liver resection? J Surg Res, 2016, 200(1): 139-146.
22.	杨淑婷, 刘斌. 控制性低中心静脉压在肝切除术中的应用进展. 华西医学, 2016, 31(4): 789-793.
23.	Smyrniotis V, Kostopanagiotou G, Theodoraki K, et al. The role of central venous pressure and type of vascular control in blood loss during major liver resections. Am J Surg, 2004, 187(3): 398-402.
24.	Li Z, Sun YM, Wu FX, et al. Controlled low central venous pressure reduces blood loss and transfusion requirements in hepatectomy. World J Gastroenterol, 2014, 20(1): 303-309.
25.	Ueno M, Kawai M, Hayami S, et al. Partial clamping of the infrahepatic inferior vena cava for blood loss reduction during anatomic liver resection: A prospective, randomized, controlled trial. Surgery, 2017, 161(6): 1502-1513.
26.	Sand L, Rizell M, Houltz E, et al. Effect of patient position and PEEP on hepatic, portal and central venous pressures during liver resection. Acta Anaesthesiol Scand, 2011, 55(9): 1106-1112.
27.	Ukere A, Meisner S, Greiwe G, et al. The influence of PEEP and positioning on central venous pressure and venous hepatic hemodynamics in patients undergoing liver resection. J Clin Monit Comput, 2017, 31(6): 1221-1228.
28.	Zatloukal J, Pradl R, Kletecka J, et al. Comparison of absolute fluid restriction versus relative volume redistribution strategy in low central venous pressure anesthesia in liver resection surgery: a randomized controlled trial. Minerva Anestesiol, 2017, 83(10): 1051-1060.
29.	Agarwal V, Divatia JV. Enhanced recovery after surgery in liver resection: current concepts and controversies. Korean J Anesthesiol, 2019, 72(2): 119-129.
30.	Feltracco P, Brezzi ML, Barbieri S, et al. Epidural anesthesia and analgesia in liver resection and living donor hepatectomy. Transplant Proc, 2008, 40(4): 1165-1168.
31.	Koul A, Pant D, Rudravaram S, et al. Thoracic epidural analgesia in donor hepatectomy: An analysis. Liver Transpl, 2018, 24(2): 214-221.
32.	Ryu HG, Nahm FS, Sohn HM, et al. Low central venous pressure with milrinone during living donor hepatectomy. Am J Transplant, 2010, 10(4): 877-882.
33.	Lee J, Kim WH, Ryu HG, et al. Stroke volume variation-guided versus central venous pressure-guided low central venous pressure with milrinone during living donor hepatectomy: a randomized double-blinded clinical trial. Anesth Analg, 2017, 125(2): 423-430.
34.	Mark J. Atlas of cardiovascular monitoring. New York: Chirchill Livingstone, 1998.
35.	Iguchi T, Ikegami T, Fujiyoshi T, et al. Low positive airway pressure without positive end-expiratory pressure decreases blood loss during hepatectomy in living liver donors. Dig Surg, 2017, 34(3): 192-196.
36.	Jayaraman S, Khakhar A, Yang H, et al. The association between central venous pressure, pneumoperitoneum, and venous carbon dioxide embolism in laparoscopic hepatectomy. Surg Endosc, 2009, 23(10): 2369-2373.
37.	Eiriksson K, Fors D, Rubertsson S, et al. High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism. Br J Surg, 2011, 98(6): 845-852.
38.	Soonawalla ZF, Stratopoulos C, Stoneham M, et al. Role of the reverse-Trendelenberg patient position in maintaining low-CVP anaesthesia during liver resections. Langenbecks Arch Surg, 2008, 393(2): 195-198.
39.	Otsuka Y, Katagiri T, Ishii J, et al. Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy? J Hepatobiliary Pancreat Sci, 2013, 20(2): 137-140.
40.	Hughes MJ, Ventham NT, Harrison EM, et al. Central venous pressure and liver resection: a systematic review and meta-analysis. HPB (Oxford), 2015, 17(10): 863-871.
41.	Mungroop TH, Geerts BF, Veelo DP, et al. Fluid and pain management in liver surgery (MILESTONE): A worldwide study among surgeons and anesthesiologists. Surgery, 2019, 165(2): 337-344.
42.	Lin CX, Guo Y, Lau WY, et al. Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int, 2013, 12(5): 520-524.

1. Mullen JT, Ribero D, Reddy SK, et al. Hepatic insufficiency and mortality in 1 059 noncirrhotic patients undergoing major hepatectomy. J Am Coll Surg, 2007, 204(5): 854-862.
2. Bui LL, Smith AJ, Bercovici M, et al. Minimising blood loss and transfusion requirements in hepatic resection. HPB (Oxford), 2002, 4(1): 5-10.
3. McNally SJ, Revie EJ, Massie LJ, et al. Factors in perioperative care that determine blood loss in liver surgery. HPB (Oxford), 2012, 14(4): 236-241.
4. Combeer EL, Quiney NF, Karanjia ND, et al. A risk score for predicting perioperative blood transfusion in liver surgery (Br J Surg 2007; 94: 860-865). Br J Surg, 2007, 94(12): 1574.
5. Lucas DJ, Schexneider KI, Weiss M, et al. Trends and risk factors for transfusion in hepatopancreatobiliary surgery. J Gastrointest Surg, 2014, 18(4): 719-728.
6. Freedman J, Luke K, Escobar M, et al. Experience of a network of transfusion coordinators for blood conservation (Ontario Transfusion Coordinators [ONTraC]). Transfusion, 2008, 48(2): 237-250.
7. Shander A, Hofmann A, Ozawa S, et al. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion, 2010, 50(4): 753-765.
8. Katz SC, Shia J, Liau KH, et al. Operative blood loss independently predicts recurrence and survival after resection of hepatocellular carcinoma. Ann Surg, 2009, 249(4): 617-623.
9. Cannon RM, Brown RE, St Hill CR, et al. Negative effects of transfused blood components after hepatectomy for metastatic colorectal cancer. Am Surg, 2013, 79(1): 35-39.
10. Correa-Gallego C, Gonen M, Fischer M, et al. Perioperative complications influence recurrence and survival after resection of hepatic colorectal metastases. Ann Surg Oncol, 2013, 20(8): 2477-2484.
11. Hill GE, Frawley WH, Griffith KE, et al. Allogeneic blood transfusion increases the risk of postoperative bacterial infection: a meta-analysis. J Trauma, 2003, 54(5): 908-914.
12. Hallet J, Tsang M, Cheng ES, et al. The impact of perioperative red blood cell transfusions on long-term outcomes after hepatectomy for colorectal liver metastases. Ann Surg Oncol, 2015, 22(12): 4038-4045.
13. Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev, 2006, (1): CD005033.
14. Rees M, Plant G, Wells J, et al. One hundred and fifty hepatic resections: evolution of technique towards bloodless surgery. Br J Surg, 1996, 83(11): 1526-1529.
15. Melendez JA, Arslan V, Fischer ME, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of post-operative renal dysfunction. J Am Coll Surg, 1998, 187(6): 620-625.
16. El-Kharboutly WS, El-Wahab MA. The role of adoption of low central venous pressure in hepatic resection with pringle manoeuvre in reducing blood loss and improving operative outcome. Egyptian J Anaesth, 2004, 20(4): 369-376.
17. Kato M, Kubota K, Kita J, et al. Effect of infra-hepatic inferior vena cava clamping on bleeding during hepatic dissection: a prospective, randomized, controlled study. World J Surg, 2008, 32(6): 1082-1087.
18. Rahbari NN, Koch M, Zimmermann JB, et al. Infrahepatic inferior vena cava clamping for reduction of central venous pressure and blood loss during hepatic resection: a randomized controlled trial. Ann Surg, 2011, 253(6): 1102-1110.
19. Wang WD, Liang LJ, Huang XQ, et al. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol, 2006, 12(6): 935-939.
20. Zhu P, Lau WY, Chen YF, et al. Randomized clinical trial comparing infrahepatic inferior vena cava clamping with low central venous pressure in complex liver resections involving the Pringle manoeuvre. Br J Surg, 2012, 99(6): 781-788.
21. Cheng ES, Hallet J, Hanna SS, et al. Is central venous pressure still relevant in the contemporary era of liver resection? J Surg Res, 2016, 200(1): 139-146.
22. 杨淑婷, 刘斌. 控制性低中心静脉压在肝切除术中的应用进展. 华西医学, 2016, 31(4): 789-793.
23. Smyrniotis V, Kostopanagiotou G, Theodoraki K, et al. The role of central venous pressure and type of vascular control in blood loss during major liver resections. Am J Surg, 2004, 187(3): 398-402.
24. Li Z, Sun YM, Wu FX, et al. Controlled low central venous pressure reduces blood loss and transfusion requirements in hepatectomy. World J Gastroenterol, 2014, 20(1): 303-309.
25. Ueno M, Kawai M, Hayami S, et al. Partial clamping of the infrahepatic inferior vena cava for blood loss reduction during anatomic liver resection: A prospective, randomized, controlled trial. Surgery, 2017, 161(6): 1502-1513.
26. Sand L, Rizell M, Houltz E, et al. Effect of patient position and PEEP on hepatic, portal and central venous pressures during liver resection. Acta Anaesthesiol Scand, 2011, 55(9): 1106-1112.
27. Ukere A, Meisner S, Greiwe G, et al. The influence of PEEP and positioning on central venous pressure and venous hepatic hemodynamics in patients undergoing liver resection. J Clin Monit Comput, 2017, 31(6): 1221-1228.
28. Zatloukal J, Pradl R, Kletecka J, et al. Comparison of absolute fluid restriction versus relative volume redistribution strategy in low central venous pressure anesthesia in liver resection surgery: a randomized controlled trial. Minerva Anestesiol, 2017, 83(10): 1051-1060.
29. Agarwal V, Divatia JV. Enhanced recovery after surgery in liver resection: current concepts and controversies. Korean J Anesthesiol, 2019, 72(2): 119-129.
30. Feltracco P, Brezzi ML, Barbieri S, et al. Epidural anesthesia and analgesia in liver resection and living donor hepatectomy. Transplant Proc, 2008, 40(4): 1165-1168.
31. Koul A, Pant D, Rudravaram S, et al. Thoracic epidural analgesia in donor hepatectomy: An analysis. Liver Transpl, 2018, 24(2): 214-221.
32. Ryu HG, Nahm FS, Sohn HM, et al. Low central venous pressure with milrinone during living donor hepatectomy. Am J Transplant, 2010, 10(4): 877-882.
33. Lee J, Kim WH, Ryu HG, et al. Stroke volume variation-guided versus central venous pressure-guided low central venous pressure with milrinone during living donor hepatectomy: a randomized double-blinded clinical trial. Anesth Analg, 2017, 125(2): 423-430.
34. Mark J. Atlas of cardiovascular monitoring. New York: Chirchill Livingstone, 1998.
35. Iguchi T, Ikegami T, Fujiyoshi T, et al. Low positive airway pressure without positive end-expiratory pressure decreases blood loss during hepatectomy in living liver donors. Dig Surg, 2017, 34(3): 192-196.
36. Jayaraman S, Khakhar A, Yang H, et al. The association between central venous pressure, pneumoperitoneum, and venous carbon dioxide embolism in laparoscopic hepatectomy. Surg Endosc, 2009, 23(10): 2369-2373.
37. Eiriksson K, Fors D, Rubertsson S, et al. High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism. Br J Surg, 2011, 98(6): 845-852.
38. Soonawalla ZF, Stratopoulos C, Stoneham M, et al. Role of the reverse-Trendelenberg patient position in maintaining low-CVP anaesthesia during liver resections. Langenbecks Arch Surg, 2008, 393(2): 195-198.
39. Otsuka Y, Katagiri T, Ishii J, et al. Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy? J Hepatobiliary Pancreat Sci, 2013, 20(2): 137-140.
40. Hughes MJ, Ventham NT, Harrison EM, et al. Central venous pressure and liver resection: a systematic review and meta-analysis. HPB (Oxford), 2015, 17(10): 863-871.
41. Mungroop TH, Geerts BF, Veelo DP, et al. Fluid and pain management in liver surgery (MILESTONE): A worldwide study among surgeons and anesthesiologists. Surgery, 2019, 165(2): 337-344.
42. Lin CX, Guo Y, Lau WY, et al. Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int, 2013, 12(5): 520-524.

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Current application status of low central venous pressure in hepatectomy

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