Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

Figures

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  Figure 1. Intraoperative hemodynamic management. Our institutional algorithm for intraoperative hemodynamic management based on target MAP and CVP. Preload dynamic indices (or stroke volume indices) are used to assess fluid responsiveness and guide vasopressor administration. Abbreviations and units. CVP, central venous pressure (mm Hg); MAP, mean arterial pressure (mm Hg); PEEP, positive end-expiratory pressure (cm H2O); SVI, stroke volume index (mL/m2); SVV, stroke volume variation (%).

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  Figure 2. Early postoperative serum lactate clearance. The horizontal axis shows serum lactate clearance (cLac) at different postoperative hours (e.g., cLac1, cLac at the 1st postoperative hour; cLac2, cLac at the 2nd postoperative hour; etc.). The vertical axis shows the relative value of lactate clearance (cLac). Lac clearance was computed using the following formula: (sLac1 – sLac2)/sLac1. Two populations with different Pringle maneuver durations (cumulative Pringle maneuver time, cPT) are plotted. Asterisk (*) means statistical significance, p < 0.05. Comment. Reduced cLac and serum lactate accumulation produce the initial drop into the cLac curve. Serum lactate levels normalize following an increase in effective lactate clearance after the third postoperative hour. These finding persuades us to routinely wait three hours after the awakening of the patient before deciding whether the patient requires postoperative surveillance in the ICU. Abbreviations. cLac, serum lactate clearance; cPT, cumulative Pringle maneuver time. Reprinted with permission from reference [46].

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  Figure 3. Decision algorithm for blood products administration. In the event of massive intraoperative bleeding (>1000 mL in less than 30 min or ongoing blood loss >150 mL/min), we agree with the surgical team to administer fresh frozen plasma (FFP) to sustain the volume. Serum hemoglobin of 7–9 g/dL is chosen as a cut-off value before starting red blood cells administration depending of patient comorbidities (preoperative anemia, cardiac status, etc.). Regarding pharmacological bleeding control, we adopt viscoelastic tests (e.g., ROTEM) as a point of care along with standard laboratory tests. Tranexamic acid, pooled platelets, fibrinogen and prothrombin complex concentrates (PCCs) are administered if coagulation tests show fibrinolysis, low platelet count (<100,000/mm3), hypofibrinogenemia and/or deficit of factors II, VII, IX, X, respectively. Temperature control and acidosis are an additional essential issue to be addressed in the event of hemorrhagic shock. Abbreviations. FFP, fresh frozen plasma; Hb, Hemoglobin; PLTs, platelet count; PPCs, prothrombin complex concentrates; RBC, red blood cells.