Published online Sep 27, 2022. doi: 10.4240/wjgs.v14.i9.1037
Peer-review started: March 18, 2022
First decision: May 12, 2022
Revised: May 25, 2022
Accepted: August 14, 2022
Article in press: August 14, 2022
Published online: September 27, 2022
Acute lung injury (ALI) post-liver transplantation (LT) may lead to acute respiratory distress syndrome, which is associated with adverse postoperative outcomes, such as prolonged hospital stay, high morbidity, and mortality. Therefore, it is vital to maintain hemodynamic stability and optimize fluid management. However, few studies have reported cardiac output-guided (CO-G) management in pediatric LT.
In this study, a randomized controlled trial was designed to evaluate the effect of CO-G algorithm management on reducing ALI events after pediatric LT and intraoperative hemodynamic stability with pressure recording analytical method (PRAM).
To investigate the effect of CO-G hemodynamic management in pediatric living donor LT on early postoperative ALI and its influence on hemodynamic stability during surgery.
A total of 130 pediatricians scheduled for elective living donor LT were enrolled as study participants and were assigned to the control group (65 cases) and CO-G group (65 cases). In the CO-G group, CO was considered the target for hemodynamic management. In the control group, hemodynamic management was based on usual perioperative care guided by central venous pressure, continuous invasive arterial pressure, urinary volume, etc. The primary outcome was early postoperative ALI. Secondary outcomes included other early postoperative pulmonary complications, readmission to the intense care unit (ICU) for pulmonary complications, ICU stay, hospital stay, and in-hospital mortality.
The incidence of early postoperative ALI was 27.7% in the CO-G group, which was significantly lower than that in the control group (44.6%) (P < 0.05). During the surgery, the incidence of postreperfusion syndrome was lower in the CO-G group (P < 0.05). The level of intraoperative positive fluid transfusions was lower and the rate of dobutamine use before portal vein opening was higher, while the usage and dosage of epinephrine when portal vein opening and vasoactive inotropic score after portal vein opening were lower in the CO-G group (P < 0.05). Compared to the control group, the serum inflammatory factors interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), cardiac troponin I (cTnI), and N-terminal-pro hormone BNP in the CO-G group were lower after the operation (P < 0.05).
CO-G hemodynamic management in pediatric living-donor LT decreased the incidence of early postoperative ALI, which is considered to benefit from hemodynamic stability through optimized fluid management and appropriate administration of vasopressors and inotropes by continuous monitoring of CO.
This is the first randomized controlled trial to evaluate the effect of CO-G hemodynamic therapy in pediatric liver recipients. In this study, hemodynamic parameters, including CO, stroke volume index, stroke volume variation, and the maximum increase in the speed of intraventricular pressure (dp/dtmax), obtained through the PRAM monitoring were used to guide intraoperative hemodynamic management. The incidence of postoperative ALI was significantly lower in the interventional group. Moreover, the inflammatory factors of IL-6, TNF-α, cTnI, decreased faster in the intervention group.