Role of the reverse-Trendelenberg patient position in maintaining low-CVP anaesthesia during liver resections

Abstract

The reverse-Trendelenberg position effectively lowers the CVP during liver surgery. It is easy to monitor, titrate and reverse, and avoids the need for complex pharmacological interventions. We recommend this position to liver surgeons and anaesthetists who have found it difficult to maintain a low CVP with the supine or Trendelenberg positions.

What Is the Preferred Central Venous Pressure Zero Reference for Hepatic Resection?

“…4 -10,12-15,25,26 However, only 3 of these studies identify a zero point reference, to which the authors refer as either "midatrial" or "right atrium" 5,12,14 without specifying exactly where this measurement was referenced. The remaining studies fail to identify any zero reference point.…”

“…[2][3][4][5][6][7][8][9][10][11] Of particular interest is the reduction of CVP to decrease congestion in hepatic veins and sinusoids to minimize resection site venous pressure, and thereby blood loss, during parenchymal dissection. This has popularized the practice of maintaining a CVP Ͻ5 mm Hg during parenchymal dissection by fluid restriction, pharmacologic intervention, patient positioning, [12][13][14] or autologous blood donation. 15 The risk of VAE increases as the CVP is decreased, and life-threatening VAE has been reported during hepatic resection despite electrocauterization, argon-enhanced coagulation, water jet dissection, ultrasonic dissection, microwave therapy, radiofrequency ablation, clamp crushing, and Cavitron Ultrasonic Surgical Aspiration (CUSA, Valleylab, Inc., Boulder, CO) 12,14,16 -22 Increasing the CVP increases the hemorrhagic risk, although decreasing the CVP introduces and increases the risk of VAE.…”

Recent advances in the management of primary hepatic tumors refinement of surgical techniques and effect on outcome

“…Maintenance intravenous fluid with occasional small boluses to maintain SBP >90 mm and urine output of 25 ml/hr is administered, 158 Trendlenberg position is used. Improved outcomes have been reported with the use of this technique [8,46]. However, its use remains institutional preference.…”

Vasopressin‐induced changes in splanchnic blood flow and hepatic and portal venous pressures in liver resection

“…1,2 Reduced blood loss has been achieved by reducing central venous pressure (CVP) 3 and has been correlated with the pressure in the inferior caval vein. 9,10 Vasopressin acts on V1 receptors in the hepato-splanchnic vascular bed and produces a potent vasoconstriction, which leads to reduced portal pressure and flow in patients with portal hypertension 11 and has been shown to reduce bleeding in liver transplantation. 9,10 Vasopressin acts on V1 receptors in the hepato-splanchnic vascular bed and produces a potent vasoconstriction, which leads to reduced portal pressure and flow in patients with portal hypertension 11 and has been shown to reduce bleeding in liver transplantation.…”

“…4 Several methods to reduce these pressures have previously been described, such as fluid restriction, use of diuretics, vasodilators (nitroglycerine infusion), 5,6 epidural anaesthesia, 7 phlebotomy 8 and changes in patient positioning. 9,10 Vasopressin acts on V1 receptors in the hepato-splanchnic vascular bed and produces a potent vasoconstriction, which leads to reduced portal pressure and flow in patients with portal hypertension 11 and has been shown to reduce bleeding in liver transplantation. 12 Terlipressin, a synthetic analogue of vasopressin, has also been shown to reduce blood loss 13 and the incidence of acute kidney injury after liver transplantation.…”