Goal directed preemptive ephedrine attenuates the reperfusion syndrome during adult living donor liver transplantation

Abstract

Background End-stage liver disease is associated with marked hemodynamic disturbances that are further deteriorated during liver transplantation and is aggressively represented in the form of postreperfusion syndrome (PRS). Aim The aim was to test the hypothesis that preemptive ephedrine administration pre-reperfusion targeting a rational level of mean arterial blood pressure (MAP) of 85-100 mmHg, may reduce the incidence of PRS. Patient and methods One hundred recipients for adult living donor liver transplantation (ALDLT) were prospectively randomized into 2 groups; group C, control group and group E, who received ephedrine 2.5-5 mg/min starting 5 min before reperfusion till mean arterial blood pressure (MAP) reached 85-100 mmHg. Hemodynamic parameters including MAP, heart rate (HR), Transesophageal Doppler (TED) parameters including corrected flow time (FTc), systemic vascular resistance (SVR), and cardiac output (COP) were measured; just predrug administration, just before reperfusion, just after reperfusion, 5 min after reperfusion and at the end of surgery. Cold and warm ischemia times (C/WIT), duration of anhepatic phase and total duration of surgery were recorded. The incidence of PRS, the need of rescue vasoconstrictor for hemodynamic instability at time of reperfusion, need for postreperfusion vasoconstrictor infusions, over shooting of hemodynamics, postreperfusion fibrinolysis indicated by fibrinogen level and maximum lysis parameter of rotational thromboelastometry (ROTEM) were compared between both groups. Results The mean dose of ephedrine required was (12.5 ± 7.5 mg). Group E had statistically significant increase in MAP, SVR, and COP; just before reperfusion, just after reperfusion and 5 min after reperfusion readings. There were no statistical significant differences between the 2 groups at the end of surgery. The incidence of PRS and the need of rescue adrenaline at the time of reperfusion, and the postreperfusion need for vasoconstrictor infusion decreased significantly in group E when compared to group C. Also postoperative mechanical ventilation decreased significantly in group E. Conclusion The preemptive goal directed titration of ephedrine against a target MAP pre-reperfusion could decrease the incidence of PRS by 40%, attenuated the hypotensive response to reperfusion and decreased the need for postreperfusion vasoconstrictor support without over shooting of any of the monitored hemodynamic indices. © 2013 Production and hosting by Elsevier B.V.