The Guidance Value Of Transesophageal Echocardiography(TEE) To Volume Management During Liver Transplantation

Objective:The application of transesophageal echocardiography examination (TEE) on the guidance of infusion therapy during cardiac surgeries and non-cardiac surgeries have been reported, but it has not been reflected in the application of liver transplantation. The goals of the present study were to study the guidance of transesophageal echocardiography(TEE) monitoring to fluid therapy and volume management during orthotopic liver transplantation, to observe the clinical effect of it in improving hemodynamics.Methods:60cirrhotic patients scheduled for OLT were enrolled, including45males and15females, ASA Ⅱ～Ⅲ grade, liver function Child-Pugh class A or B grade, aged32to64years old, weighing54～93kg. Patients were randomly divided into two groups:30patients in TEE monitoring group and30cases in the control group. In control group, the fluctuation range of mean arterial pressure (MAP) and heart rate(HR) and central venous pressure (CVP) were maintained less than20%of the base value, while the urine volume kept more than1ml/kg/h. For TEE group, Sinclair’s method was adopted that fluid was input to keep corrective left ventricular ejection time (LVETc) got by TEE between0.35s to0.40s. When the LVETc below0.35s, the infusion speed should be rised. When the LVETc above0.40s, the infusion speed should be decreased. The Measurements of average invasive arterial pressure (MABP), mean pulmonary arterial pressure (MPAP), central venous pressure (CVP), cardiac output (CO) were performed at standard times:(1) immediately before incision (To);(2)60min after the operation began (T1);(3)10min after anhepatic phase began (T2);(4)10min after portal vein reperfusion (T3);(5)60min after portal vein reperfusion (T4);(6) at the end of surgery. The amount of intraoperative blood transfusion, urine output, cardiovascular adverse events including negative hemodynamic fluctuations and myocardial ischemia were recorded. Postoperative ICU residence time and the occurrence of adverse events including pulmonary edema, myocardial infarction, renal failure, cognitive dysfunction and death were also recorded,Results:Both of the groups remained the stable hemodynamic parameters (MABP, MPAP, CVP, CO) before anhepatic stage (T0, T1). The conventional hemodynamic parameters were significant fluctuations after the anhepatic stage, suggesting the presence of severe hemodynamic changes during liver transplantation; Compared to the control group, TEE monitoring group remained relatively stable hemodynamic parameters after the anhepatic stage (T3, T4, T5), TEE monitoring fluid therapy can reduce the hemodynamic change during liver transplantation; There was no difference between two groups in infusion of crystals, colloids, red blood cells, plasma total infusion volume and the amount of bleeding. Compared to the control group, the urine volume was relatively more. As for the intraoperative and postoperative adverse cardiovascular events, TEE monitoring group were significantly lower than the control group, suggesting that TEE monitoring can reasonably guide transfusion transfusion to reduce the PRS of the vital organs including the kidney, heart.Conclusion:During liver transplantation, the application of TEE for fluid therapy can detect the hemodynamic change and effectively maintain hemodynamic stability, improve patient vital organ perfusion, reduce perioperative adverse events, postoperative extubation time and ICU stay offline time and improve outcomes.