Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients - results after three years of practice

Table 1 Fast track protocol for cirrhotic patients undergoing liver resection

Fast track protocol for cirrhotic patients undergoing liver resection
Preoperative counseling
Regular diet on the day before surgery
No bowel preparation
Intraoperative CVP target < 6 mmHg, restricted fluids administration
ICU admission for at least the first post-operative night (or on POD 0)
Maintenance fluids discontinued on POD 3
Nasogastric probe removal on POD 1
Liquid diet on POD 1
Regular diet on POD 3
Urinary catheter discontinued on POD 3
Drains removal on POD 3
Ambulation on POD 3
Discharge criteria: Liver and kidney function tests compatible with preoperative data or decreasing, able to tolerate food intake, able to ambulate, good pain control (NRS < 3)

ICU: Intensive care unit; CVP: Central venous pressure; POD: Postoperative days; NRS: Numerical rating scale.

Table 2 Preoperative data

	Group no epidural (n = 86)	Group epidural (n = 40)	P
Sex male (%)	69 (80.2%)	30 (75%)	0.655
Age (yr)	63.28 ± 11.38	62.8 ± 11.92	0.832
BMI	26.65 ± 4.36	25.23 ± 5.50	0.155
Cirrhosis etiology
HBV	19	10	0.947
HCV	49	27	0.434
Alcohol	9	2	0.501
Other	13	3	0.341
Type of resection
Major	19	12	0.461
Minor	67	28
Preoperative data
AST (UI/L)	50.8 ± 47.4	46.9 ± 29.1	0.586
ALT(UI/L)	47.4 ± 43.1	52.3 ± 38.5	0.541
Bilirubin (mg/dL)	0.80 ± 0.43	0.77 ± 0.40	0.710
INR	1.14 ± 0.12	1.10 ± 0.79	0.092
Creatinine (mg/dL)	1.08 ± 1.24	0.87 ± 0.26	0.164
Urea (mg/dL)	37.25 ± 13.74	36.84 ± 11.79	0.867
Platelet count	180134 ± 83856	211079 ± 94262	0.088

HBV: Hepatitis B virus; BMI: Body mass index; HCV: Hepatitis C virus; AST: Aspertate aminotransferase; ALT: Alanine transaminase; INR: International normalized ratio.

Table 3 Intraoperative data

		Group no epidural (n = 86)	Group epidural (n = 40)	P
Hemodynamic parameters
MAP	Baseline	94.4 ± 12	89.5 ± 11.8	0.035
(mmHg)	Post-resection	77.3 ± 16.9	71.2 ± 9.7	0.041
(P = 0.004)	End of surgery	74.9 ± 10.7	74.9 ± 10.7	0.048
CVP	Baseline	8.26 ± 3.4	8.92 ± 3.15	0.323
(mmHg)	Post-resection	6.0 ± 3.25	5.76 ± 3.13	0.704
(P = 0.991)	End of surgery	7.35 ± 3.13	6.92 ± 2.57	0.466
Metabolic parameters
pH	Baseline	7.44 ± 0.043	7.44 ± 0.055	0.717
(P = 0.627)	Post-resection	7.40 ± 0.053	7.39 ± 0.053	0.608
	End of surgery	7.38 ± 0.573	7.39 ± 0.062	0.258
Lac (mmol/L)	Baseline	2.07 ± 3.15	1.98 ± 3.11	0.925
(P = 0.894)	Post-resection	4.22 ± 6.11	4.68 ± 7.40	0.800
	End of surgery	2.59 ± 2.20	2.62 ± 1.88	0.958
BE (mEq/L)	Baseline	1.27 ± 2.10	1.6 ± 1.94	0.563
(P = 0.343)	Post-resection	-1.93 ± 2.37	-1.31 ± 2.61	0.354
	End of surgery	-2.72 ± 2.88	-2.56 ± 2.92	0.499
Other data
Lenght of surgery (min)		250.4 ± 93.48	267.6 ± 88.97	0.326
Hypotension duration (min)		2.28 ± 4.52	5.43 ± 6.68	0.006
Cristalloids infusions (mL)		2768 ± 1213	2574 ± 1022	0.354
Colloids infusions (mL)		259 ± 320	428 ± 312	0.007
RBC transfusions (U)		0.06 ± 0.239	0.01 ± 0.304	0.470
Total diuresis (mL)		467 ± 376	552 ± 384	0.248

MAP: Mean arterial pressure; RBC: Red blood count; Lac: Lactate; BE: Base excess; CVP: Central venous pressure.

Table 4 Post-operative data

		Group no epidural (n = 86)	Group epidural (n = 40)	P
Hepatic function tests
AST (UI/L)	POD 1	205 ± 141	238 ± 168	0.239
(P = 0.451)	POD 3	97 ± 66	96 ± 54	0.334
	POD 7	49 ± 29	52 ± 26	0.636
ALT (UI/L)	POD 1	195 ± 161	229 ± 210	0.144
(P = 0.605)	POD 3	157 ± 126	157 ± 106	0.391
	POD 7	67 ± 47	73 ± 40	0.884
Bilirubin (mg/dL)	POD 1	1.60 ± 1.0	1.60 ± 0.88	0.994
(P = 0.557)	POD 3	1.8 ± 1.05	1.57 ± 0.81	0.306
	POD 7	1.38 ± 1.06	1.26 ± 1.31	0.636
INR	POD 1	1.34 ± 0.18	1.31 ± 0.20	0.593
(P = 0.544)	POD 3	1.31 ± 0.16	1.30 ± 0.25	0.899
	POD 7	1.26 ± 0.14	1.12 ± 0.15	0.319
Platelet count	POD 1	163649 ± 78332	148015 ± 72007	0.647
(P = 0.532)	POD 3	148015 ± 72007	132275 ± 43514	0.277
	POD 7	191073 ± 74978	187586 ± 63602	0.827
Kidney function tests
Creatinine (mg/dL)	POD 1	0.96 ± 0.87	0.87 ± 0.42	0.579
(P = 0.417)	POD 3	0.98 ± 1.04	0.79 ± 0.29	0.331
	POD 7	0.96 ± 1.15	0.78 ± 0.28	0.410
Urea (mg/dL)	POD 1	33.37 ± 13.87	32.86 ± 12.17	0.866
(P = 0.315)	POD 3	38.0 ± 21.17	33.79 ± 14.27	0.332
	POD 7	35.57 ± 20.13	29.76 ± 11.67	0.151

For repeated measures, the P value expressed under the variable is referred to the between subjects effect test. AST: Aspertate aminotransferase; ALT: Alanine transaminase; INR: International normalized ratio; POD: Postoperative days.

Table 5 Hospital length of stay and complications

	Group no epidural (n = 86)	Group epidural (n = 40)	P
Post operative MV lenght (h)	7.34 ± 18.11	1.29 ± 1.74	0.003
ICU stay (d)	2.78 ± 2.35	2.43 ± 1.57	0.183
Total PO hospital stay (d)	11.49 ± 7.95	8.65 ± 3.26	0.032
AKIN (grade)
0	81	40	0.121
1	3	0
2	1	0
3	1	0
DINDO (grade)
1	30	15	0.262
2	19	9
3	10	1
4	0	0
5	0	0

MV: Mechanical ventilation; PO: Postoperative; AKIN: Acute kidney injury network classification; DINDO: Clavien dindo classification of surgical complications.