IntroductionInvasive blood pressure monitoring is essential in liver transplant surgery due to expected major hemodynamic shifts. The use of central versus peripheral arterial access, however, is institution-dependent, which can affect clinical decisions regarding vasopressor therapy. Although there are studies that demonstrate inconsistencies based on arterial cannulation sites, few studies have compared femoral and radial artery blood pressures in patients undergoing liver transplant surgery. To our knowledge, there are no studies investigating the differences between continuous minute-to-minute femoral and radial artery measurements during all three phases of liver transplant surgery. ObjectiveThe main objective of this study was to evaluate for any differences between central and peripheral blood pressure measurements in liver transplant surgery and to assess for any correlation between vasopressor infusion dose and femoral-arterial pressure differences. MethodsIn this retrospective study, we reviewed and studied the data of 61 patients with American Society of Anesthesiologists (ASA) grade 4 who underwent liver transplant surgery at Loma Linda University Medical Center between January and December of 2019. All patients had both femoral and radial arterial lines placed for liver transplant surgery. Femoral and radial arterial blood pressure values were obtained continuously over 60 minutes in the pre-anhepatic phase, 45 minutes during the anhepatic phase, and 60 minutes into the neo-hepatic phase. Vasopressor infusion doses were also recorded for each patient during these time frames. ResultsThis pilot study found statistically significant differences between the mean femoral and radial systolic blood pressure (SBP; p < 0.0001), diastolic blood pressure (DBP; p < 0.0001), and mean arterial pressure (MAP; p < 0.0001) during all phases of liver transplantation. The mean SBP and MAP differences between femoral and radial arteries were highest (femoral blood pressure reading higher than radial blood pressure measurements) in the late anhepatic and early neo-hepatic phases with SBP differences of 20.8 ± 0.8 mmHg and 22.8 ± 0.8 mmHg, respectively, and MAP differences of 10.0 ± 0.4 mmHg and 9.8 ± 0.4 mmHg, respectively. Higher vasopressor infusion doses were strongly associated with greater differences in femoralradial SBP and MAP measurements (r = 0.69 for vasopressin, 0.68 for norepinephrine, and 0.68 for epinephrine; p < 0.0001) during the anhepatic phase. ConclusionsPeripheral invasive blood pressure monitoring may result in underestimation of the central blood pressure, as was seen in all phases of liver transplantation. This may lead to excessive vasopressor use with potentially adverse effects. Although the cause for the difference between femoral and radial artery measurements is unclear, increasing vasopressor infusion dosages appears to contribute. Femoral artery blood pressure monitoring allows clinicians to interpret hemodynamic status and administer appropriate vasopressors more accurately.
Lean Six Sigma (LSS) is a process improvement strategy used in many industries. Its goal is to improve performance and quality by eliminating waste, optimizing flow, and reducing variability. This article describes LSS methods and their application in health care. We detail a successful quality improvement (QI) initiative in which we tested LSS tools to evaluate and enhance our institution's blood product delivery to the operating room (OR). Incorporating LSS-driven changes resulted in a revised workflow, which decreased personnel workload and significantly reduced delivery time. We hope this article will encourage other health care institutions to integrate LSS strategies into their workflows. (A&A Practice. 2021;15:e01463.
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