The Change of Respiratory Compliance Before and After Removal of Ascites in Living Donor Liver Transplantation T.-H. Shih, S.-C. Yang, C.-L. Chen, C.-H. Wang, K.-W. Cheng, C.-J. Huang, B. Jawan, and S.-C. Wu ABSTRACT Background. The study’s purpose was to evaluate the effects of total removal of the asictes through laparotomy on the lung function of adult patients undergoing living donor liver transplantation. Basis Procedure. One hundred eleven patients were reviewed retrospectively. Patients were grouped into 3 groups: GI had ascites 4000 mL. The respiratory compliance (RC), end-tidal carbon dioxide (EtCO2), peak and plateau airway pressures, tidal volume, and ventilator modes used were compared from 5 minutes before to 20 minutes after laparotomy, by using linear regression and repeated measurements. The changes in the RC among groups were tested using one-way analysis of variance (ANOVA), whereas the changes in percentage of the RC in the same group were tested using paired Student t test. Main Findings. The changes in RC before and 10 minutes after laparotomy and total removal of the ascites were 45 12 to 47 13, 39 9 to 43 6, and 24 8 to 43 12 mL/cm H2O for GI, GII, and GIII, respectively. Linear regression analysis showed that the R2 of the RC 20 minutes after removal of the ascites was 0.645. Pressure cycled ventilation (PCV) used in GIII significantly increased the tidal volume and low end tidal CO2 after laparotomy. Conclusions. Removal of the ascites in patients undergoing living donor liver transplantation (LDLT) tended to improve the RC in all groups, but significant change was only noted in patients with massive ascites (GIII). Resetting of the ventilator is required to prevent hyperventilation when the PCV mode is used in GIII.
A
SCITES is common in patients with end-stage liver disease requiring liver transplantation [1,2]. In the liver transplantation setting, the ascites is usually totally suctioned immediately after opening of the abdomen. Furthermore, the patients are under anesthesia and mechanical ventilation [3], either volume cycled ventilation (VCV) mode or pressure cycled ventilation (PCV) mode. The overall effect of rapid removal of the ascites through surgical suction in patients with open abdomen and under positive pressure ventilation is to be elucidated. The aim of the current study was to evaluate the effect of rapid removal of the ascites by laparotomy on the changes in the respiratory compliance (RC) and other respiratory parameters in adult patients with end-stage liver disease undergoing living donor liver transplantation (LDLT), and the clinical cost benefit of VCV versus PCV was compared retrospectively. 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.09.049 730
MATERIAL AND METHODS The approval of the Institutional Review Board (101-1218B) was obtained. The anesthesia records of patients undergoing LDLT at the Kaohsiung Chang Gung Memorial Hospital, Taiwan from January 1, 2011 to December 31, 2011 were reviewed retrospectively. The anesthesia and monitoring of the patients were similar as previously reported [4,5]. General endotracheal anesthesia was given by using S/5 Anesthesia Delivery Unit Carestation (Datex-Ohmeda, GE Healthcare, Madison, Wis, United States). RC was continuously From the Departments of Anesthesiology (T.-H.S., S.-C.Y., C.-H.W., K.-W.C., C.-J.H., B.J., S.-C.W.), Liver Transplantation Program and Surgery (C.-L.C.), Kaohsiung Chang Gung Memorial and Chang Gung University College of Medicine, Kaohsiung, Taiwan. Address reprint requests to Shao-Chun Wu, MD, Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. E-mail: [email protected] ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 730e732 (2014)
RESPIRATORY COMPLIANCE AND MASSIVE ASCITES monitored using side-stream sampling with the same anesthesia machine. Ventilation was controlled, either with volume cycled mode or pressure cycled mode, to keep an end-tidal carbon dioxide concentration between 30 and 35 mm Hg. After opening of the abdomen, all the ascites was suctioned by the surgeons. The amount of ascites was recorded. The RC, end-tidal carbon dioxide (EtCO2) concentrations, peak, and plateau airway pressures, tidal volume, and ventilator mode were collected, analyzed, and compared from 5 minutes before and 20 minutes after opening of the abdominal cavity by using linear regression and repeated measurement. The patients were also divided into 3 groups according to the amount of the ascites removed. Patients with ascites 4000 mL in group 3 (GIII). Patients’ characteristics and the change in respiratory parameters among the groups at 5 minutes before and 10 and 20 minutes after opening of the abdomen were compared by using one-way analysis of variance (ANOVA)for continuous variables. The change in RC, in percentage (%), in the same group was tested using paired Student t test. It was calculated by using RC at 10 minutes after laparotomy minus RC at 5 minutes before laparotomy divided by RC at 5 minutes. P < .05 was regarded as significant. Data was given in mean standard deviation.
RESULTS
A total of 111 adult patients were included in this study. There were 70 patients in GI, 20 patients in GII, and 21 patients in GIII. Their demographic data and respiratory data are presented in Table 1. The initial RC of GIII was significantly lower than that of GI and GII (Table 1 and Fig 1). Figure 1 shows that 10 and 20 minutes after opening of the
731
abdomen and complete removal of the ascites tended to improve the RC in all groups, but drastic and significant changes were only observed in GIII. The changes in RC before and 10 minutes after laparotomy were 45 12 to 47 13, 39 9 to 43 6, and 24 8 to 43 12 mL/cm H2O for GI, GII, and GIII, respectively. After opening of the abdomen, the RC was similar in all groups. Other respiratory parameters such as peak and plateau airway pressures, tidal volume, and end tidal EtCO2 are given in Table 1. Peak and plateau airway pressures were higher, and the tidal volume was lower in GIII compared with GI and GII before laparotomy. Ten minutes after laparotomy, tidal volume and the airway pressures of GIII normalized to a value similar to that of GI and GII. Concerning the effect of different ventilator modes on the changes in the tidal volume, EtCO2, and peak and plateau airway pressures after removal of the ascites, it revealed the both VCV and PCV modes did not significantly alter the respiratory parameters in GI and GII but had significant effects in GIII. When PCV was used, the changes in peak and plateau airway pressures were not remarkable, but a significant increase in tidal volume associated with low EtCO2 was noted. Under VCV mode, no changes in tidal volume and EtCO2 were noted, but a significant decrease in peak and plateau airway pressures was found after laparotomy. DISCUSSION
Our results show that opening of the abdomen followed by complete suction of the ascites in patients undergoing
Table 1. Patients’ Demographic Data and Recorded Data
Age (y) Height (cm) Weight (kg) Ascites (mL) Respiratory compliance (0 min; mL/cm H2O) RC (10 min; mL/cm H2O) RC (20 min; mL/cm H2O) EtCO2 (0 min; mm Hg) EtCO2 (10 min; mm Hg) EtCO2 (20 min; mm Hg) Tidal volume (0 min; mL) Tidal volume (10 min; mL) Tidal volume (20 min; mL) Peak pressure (0 min; cm H2O) Peak pressure (10 min; cm H2O) Peak pressure (20 min; cm H2O) Plateau pressure (0 min; cm H2O) Plateau pressure (10 min; cm H2O) Plateau pressure (20 min; cm H2O) VCV/PCV mode (n) Compliance change in % (0 min) Compliance change in % (10 min) Compliance change in % (20 min) Note: P < .05. *GI vs GII. † GI vs GIII. ‡ GII vs GIII.
GI (n ¼ 70)
GII (n ¼ 20)
GIII (n ¼ 21)
P
53 9 163 9 65 13 80 173 45 12 47 13 49 15 32 2 32 2 32 2 578 93 584 95 585 99 21 4 21 4 20 3 16 3 16 3 15 3 68/2 1 7 4 11 9 18
53 8 164 9 65 12 2465 813 39 9 43 6 45 7 32 3 32 3 33 3 562 121 572 107 571 106 22 4 21 4 20 4 18 4 16 3 16 3 19/1 3 7 9 21 14 19
60 6 164 8 70 12 10,590 6091 24 8 43 12 46 15 32 4 31 2 30 3 497 112 598 183 558 109 27 3 21 4 20 4 24 3 17 4 16 4 14/7 2 11 101 90 110 88
†,‡
*,†,‡ †,‡
†,‡ †,‡
†,‡
†,‡
†,‡ †,‡
732
Fig 1. The changes of the RC after removal of ascites among the groups. *Significant difference in comparison with their own compliance before removal of ascites. #Significant difference in comparison with the change of lung compliance in minimal ascites (GI). $Significant difference in comparison with the change of lung compliance in moderate ascites (GII).
LDLT tended to improve the RC in all groups, but only patients with massive ascites (GIII) showed a significant change (Table 1 and Fig 1). The degree of improvement of the RC seems to relate to their previous abdominal pressure. Linear regression analysis of the results revealed that the change in the RC in percentage was indeed significantly correlated with the amount of the ascites removed (R2, 0.645). The abdomen is the inferior part of the chest wall; abdominal distention from various causes, such as pregnancy [6] and ascites [1], leads to increased abdominal pressure, subsequently elevating the diaphragm. Passive elevation of the diaphragm allows transmission of the high intra-abdominal pressure to the pleural cavity, resulting in stiffening of the diaphragm and chest wall. Likewise, it also leads to increased intrathoracic pressure, reducing the lung volume, functional residual capacity, and RC [1,2,6,7]. Laparotomy releases the intra-abdominal pressure, allowing the elevated diaphragm, as the inferior part of the chest wall [8], to be moved down with less resistance under controlled ventilation, facilitating the lung expansion, and subsequently improving the RC [8]. The improvement in RC of GI and GII were relatively small or clinically irrelevant, but the change in RC of GIII was almost doubled from 24 8 to 43 12 cm H2O (Fig 1 and Table 1). The cause of the low RC
SHIH, YANG, CHEN ET AL
is more mechanical rather than pathological. A successful liver transplantation will cure the portal hypertension of the patient, substantially solving the problem of ascites, and will improve or normalize the RC to a level comparable with that of the subject without ascites as shown in the current study. Table 1 also revealed that most of the GI and GII received VCV mode, whereas half of the GIII patients received PCV mode for mechanical ventilation. The VCV mode resulted in high airway pressure alarms that required a shift to PCV mode. Both modes can be used safely and provide sufficient oxygenation and ventilation to maintain EtCO2 at a desired level of 30e35 mm Hg. However, our results revealed that laparotomy and removal of ascites had increased the tidal volume 2-fold to 3-fold due to sudden improvement of the RC in GIII. Therefore, resetting of the pressure in PCV was required to prevent overinflation of the lungs. In contrast, when VCV mode was used, no change in the tidal volume was seen. An immediate decrease of the peak airway pressure was observed, requiring no resetting of the ventilation. In conclusion, removal of the ascites in patients undergoing LDLT tended to improve the RC in all groups, but significant change was only noted in patients with massive ascites (GIII). Resetting of the ventilator is required to prevent hyperventilation when PCV mode is used in GIII.
REFERENCES [1] Choudhury J, Sanyal AJ. Treatment of ascites. Curr Treat Options Gastroenterol 2003;6:481e91. [2] Angueira CE, Kadakia SC. Effects of large-volume paracentesis on pulmonary function in patients with tense cirrhotic ascites. Hepatology 1994;20:825e8. [3] Tallgren M, Hockerstedt K, Lindgren L. Respiratory compliance during orthotopic liver transplantation. Acta Anaesthesiol Scand 1996;40:760e4. [4] Jawan B, de Villa V, Luk HN, et al. Ionized calcium changes during living-donor liver transplantation in patients with and without administration of blood-bank products. Transpl Int 2003;16: 510e4. [5] Jawan B, de Villa V, Luk HN, et al. Perioperative normovolemic anemia is safe in pediatric living-donor liver transplantation. Transplantation 2004;77:1394e8. [6] Gee JB, Packer BS, Millen JE, et al. Pulmonary mechanics during pregnancy. J Clin Invest 1967;46:945e52. [7] Auler JO Jr, Miyoshi E, Fernandes CR, et al. The effects of abdominal opening on respiratory mechanics during general anesthesia in normal and morbidly obese patients: a comparative study. Anesth Analg 2002;94:741e8. [8] Mutoh T, Lamm WJ, Embree LJ, et al. Abdominal distension alters regional pleural pressures and chest wall mechanics in pigs in vivo. J Appl Physiol 1991;70:2611e8.
A
SCITES is common in patients with end-stage liver disease requiring liver transplantation [1,2]. In the liver transplantation setting, the ascites is usually totally suctioned immediately after opening of the abdomen. Furthermore, the patients are under anesthesia and mechanical ventilation [3], either volume cycled ventilation (VCV) mode or pressure cycled ventilation (PCV) mode. The overall effect of rapid removal of the ascites through surgical suction in patients with open abdomen and under positive pressure ventilation is to be elucidated. The aim of the current study was to evaluate the effect of rapid removal of the ascites by laparotomy on the changes in the respiratory compliance (RC) and other respiratory parameters in adult patients with end-stage liver disease undergoing living donor liver transplantation (LDLT), and the clinical cost benefit of VCV versus PCV was compared retrospectively. 0041-1345/14/$esee front matter http://dx.doi.org/10.1016/j.transproceed.2013.09.049 730
MATERIAL AND METHODS The approval of the Institutional Review Board (101-1218B) was obtained. The anesthesia records of patients undergoing LDLT at the Kaohsiung Chang Gung Memorial Hospital, Taiwan from January 1, 2011 to December 31, 2011 were reviewed retrospectively. The anesthesia and monitoring of the patients were similar as previously reported [4,5]. General endotracheal anesthesia was given by using S/5 Anesthesia Delivery Unit Carestation (Datex-Ohmeda, GE Healthcare, Madison, Wis, United States). RC was continuously From the Departments of Anesthesiology (T.-H.S., S.-C.Y., C.-H.W., K.-W.C., C.-J.H., B.J., S.-C.W.), Liver Transplantation Program and Surgery (C.-L.C.), Kaohsiung Chang Gung Memorial and Chang Gung University College of Medicine, Kaohsiung, Taiwan. Address reprint requests to Shao-Chun Wu, MD, Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Taiwan. E-mail: [email protected] ª 2014 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710 Transplantation Proceedings, 46, 730e732 (2014)
RESPIRATORY COMPLIANCE AND MASSIVE ASCITES monitored using side-stream sampling with the same anesthesia machine. Ventilation was controlled, either with volume cycled mode or pressure cycled mode, to keep an end-tidal carbon dioxide concentration between 30 and 35 mm Hg. After opening of the abdomen, all the ascites was suctioned by the surgeons. The amount of ascites was recorded. The RC, end-tidal carbon dioxide (EtCO2) concentrations, peak, and plateau airway pressures, tidal volume, and ventilator mode were collected, analyzed, and compared from 5 minutes before and 20 minutes after opening of the abdominal cavity by using linear regression and repeated measurement. The patients were also divided into 3 groups according to the amount of the ascites removed. Patients with ascites 4000 mL in group 3 (GIII). Patients’ characteristics and the change in respiratory parameters among the groups at 5 minutes before and 10 and 20 minutes after opening of the abdomen were compared by using one-way analysis of variance (ANOVA)for continuous variables. The change in RC, in percentage (%), in the same group was tested using paired Student t test. It was calculated by using RC at 10 minutes after laparotomy minus RC at 5 minutes before laparotomy divided by RC at 5 minutes. P < .05 was regarded as significant. Data was given in mean standard deviation.
RESULTS
A total of 111 adult patients were included in this study. There were 70 patients in GI, 20 patients in GII, and 21 patients in GIII. Their demographic data and respiratory data are presented in Table 1. The initial RC of GIII was significantly lower than that of GI and GII (Table 1 and Fig 1). Figure 1 shows that 10 and 20 minutes after opening of the
731
abdomen and complete removal of the ascites tended to improve the RC in all groups, but drastic and significant changes were only observed in GIII. The changes in RC before and 10 minutes after laparotomy were 45 12 to 47 13, 39 9 to 43 6, and 24 8 to 43 12 mL/cm H2O for GI, GII, and GIII, respectively. After opening of the abdomen, the RC was similar in all groups. Other respiratory parameters such as peak and plateau airway pressures, tidal volume, and end tidal EtCO2 are given in Table 1. Peak and plateau airway pressures were higher, and the tidal volume was lower in GIII compared with GI and GII before laparotomy. Ten minutes after laparotomy, tidal volume and the airway pressures of GIII normalized to a value similar to that of GI and GII. Concerning the effect of different ventilator modes on the changes in the tidal volume, EtCO2, and peak and plateau airway pressures after removal of the ascites, it revealed the both VCV and PCV modes did not significantly alter the respiratory parameters in GI and GII but had significant effects in GIII. When PCV was used, the changes in peak and plateau airway pressures were not remarkable, but a significant increase in tidal volume associated with low EtCO2 was noted. Under VCV mode, no changes in tidal volume and EtCO2 were noted, but a significant decrease in peak and plateau airway pressures was found after laparotomy. DISCUSSION
Our results show that opening of the abdomen followed by complete suction of the ascites in patients undergoing
Table 1. Patients’ Demographic Data and Recorded Data
Age (y) Height (cm) Weight (kg) Ascites (mL) Respiratory compliance (0 min; mL/cm H2O) RC (10 min; mL/cm H2O) RC (20 min; mL/cm H2O) EtCO2 (0 min; mm Hg) EtCO2 (10 min; mm Hg) EtCO2 (20 min; mm Hg) Tidal volume (0 min; mL) Tidal volume (10 min; mL) Tidal volume (20 min; mL) Peak pressure (0 min; cm H2O) Peak pressure (10 min; cm H2O) Peak pressure (20 min; cm H2O) Plateau pressure (0 min; cm H2O) Plateau pressure (10 min; cm H2O) Plateau pressure (20 min; cm H2O) VCV/PCV mode (n) Compliance change in % (0 min) Compliance change in % (10 min) Compliance change in % (20 min) Note: P < .05. *GI vs GII. † GI vs GIII. ‡ GII vs GIII.
GI (n ¼ 70)
GII (n ¼ 20)
GIII (n ¼ 21)
P
53 9 163 9 65 13 80 173 45 12 47 13 49 15 32 2 32 2 32 2 578 93 584 95 585 99 21 4 21 4 20 3 16 3 16 3 15 3 68/2 1 7 4 11 9 18
53 8 164 9 65 12 2465 813 39 9 43 6 45 7 32 3 32 3 33 3 562 121 572 107 571 106 22 4 21 4 20 4 18 4 16 3 16 3 19/1 3 7 9 21 14 19
60 6 164 8 70 12 10,590 6091 24 8 43 12 46 15 32 4 31 2 30 3 497 112 598 183 558 109 27 3 21 4 20 4 24 3 17 4 16 4 14/7 2 11 101 90 110 88
†,‡
*,†,‡ †,‡
†,‡ †,‡
†,‡
†,‡
†,‡ †,‡
732
Fig 1. The changes of the RC after removal of ascites among the groups. *Significant difference in comparison with their own compliance before removal of ascites. #Significant difference in comparison with the change of lung compliance in minimal ascites (GI). $Significant difference in comparison with the change of lung compliance in moderate ascites (GII).
LDLT tended to improve the RC in all groups, but only patients with massive ascites (GIII) showed a significant change (Table 1 and Fig 1). The degree of improvement of the RC seems to relate to their previous abdominal pressure. Linear regression analysis of the results revealed that the change in the RC in percentage was indeed significantly correlated with the amount of the ascites removed (R2, 0.645). The abdomen is the inferior part of the chest wall; abdominal distention from various causes, such as pregnancy [6] and ascites [1], leads to increased abdominal pressure, subsequently elevating the diaphragm. Passive elevation of the diaphragm allows transmission of the high intra-abdominal pressure to the pleural cavity, resulting in stiffening of the diaphragm and chest wall. Likewise, it also leads to increased intrathoracic pressure, reducing the lung volume, functional residual capacity, and RC [1,2,6,7]. Laparotomy releases the intra-abdominal pressure, allowing the elevated diaphragm, as the inferior part of the chest wall [8], to be moved down with less resistance under controlled ventilation, facilitating the lung expansion, and subsequently improving the RC [8]. The improvement in RC of GI and GII were relatively small or clinically irrelevant, but the change in RC of GIII was almost doubled from 24 8 to 43 12 cm H2O (Fig 1 and Table 1). The cause of the low RC
SHIH, YANG, CHEN ET AL
is more mechanical rather than pathological. A successful liver transplantation will cure the portal hypertension of the patient, substantially solving the problem of ascites, and will improve or normalize the RC to a level comparable with that of the subject without ascites as shown in the current study. Table 1 also revealed that most of the GI and GII received VCV mode, whereas half of the GIII patients received PCV mode for mechanical ventilation. The VCV mode resulted in high airway pressure alarms that required a shift to PCV mode. Both modes can be used safely and provide sufficient oxygenation and ventilation to maintain EtCO2 at a desired level of 30e35 mm Hg. However, our results revealed that laparotomy and removal of ascites had increased the tidal volume 2-fold to 3-fold due to sudden improvement of the RC in GIII. Therefore, resetting of the pressure in PCV was required to prevent overinflation of the lungs. In contrast, when VCV mode was used, no change in the tidal volume was seen. An immediate decrease of the peak airway pressure was observed, requiring no resetting of the ventilation. In conclusion, removal of the ascites in patients undergoing LDLT tended to improve the RC in all groups, but significant change was only noted in patients with massive ascites (GIII). Resetting of the ventilator is required to prevent hyperventilation when PCV mode is used in GIII.
REFERENCES [1] Choudhury J, Sanyal AJ. Treatment of ascites. Curr Treat Options Gastroenterol 2003;6:481e91. [2] Angueira CE, Kadakia SC. Effects of large-volume paracentesis on pulmonary function in patients with tense cirrhotic ascites. Hepatology 1994;20:825e8. [3] Tallgren M, Hockerstedt K, Lindgren L. Respiratory compliance during orthotopic liver transplantation. Acta Anaesthesiol Scand 1996;40:760e4. [4] Jawan B, de Villa V, Luk HN, et al. Ionized calcium changes during living-donor liver transplantation in patients with and without administration of blood-bank products. Transpl Int 2003;16: 510e4. [5] Jawan B, de Villa V, Luk HN, et al. Perioperative normovolemic anemia is safe in pediatric living-donor liver transplantation. Transplantation 2004;77:1394e8. [6] Gee JB, Packer BS, Millen JE, et al. Pulmonary mechanics during pregnancy. J Clin Invest 1967;46:945e52. [7] Auler JO Jr, Miyoshi E, Fernandes CR, et al. The effects of abdominal opening on respiratory mechanics during general anesthesia in normal and morbidly obese patients: a comparative study. Anesth Analg 2002;94:741e8. [8] Mutoh T, Lamm WJ, Embree LJ, et al. Abdominal distension alters regional pleural pressures and chest wall mechanics in pigs in vivo. J Appl Physiol 1991;70:2611e8.
