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Anesth Analg 2002;95:1173-1178
© 2002 International Anesthesia Research Society

CARDIOVASCULAR ANESTHESIA

Hemodynamic and Hormonal Responses to the Sudden Interruption of Caval Flow: Insights from a Prospective Study of Hepatic Vascular Exclusion During Major Liver Resections

Daniel Eyraud, MD*, Olivier Richard, MD*, Dominique C. Borie, MD PhD{dagger}, Barbara Schaup, MD*, Alain Carayon, MD PhD{ddagger}, Corinne Vézinet, MD*, Marie Movschin, MD*, Jean-Christophe Vaillant, MD{dagger}, Pierre Coriat, MD*, and Laurent Hannoun, MD

Departments of *Anesthesiology and Critical Care, {dagger}Hepato-Biliary Surgery and Liver Transplantation, and {ddagger}Biochemistry and Molecular Biology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie, Paris, France

Address correspondence and reprint requests to Daniel Eyraud, MD, Department of Anesthesiology and Critical Care, Groupe Hospitalier Pitié-Salpêtrière, 47 Blvd. de l’Hôpital, 75013 Paris, France. Address e-mail to daniel.eyraud{at}psl.ap-hop-paris.fr

Hepatic vascular exclusion (HVE) combines portal triad clamping and occlusion of the inferior vena cava. Although HVE has been performed for major liver resections during the last 2 decades, little is known about the mechanisms that explain its satisfactory hemodynamic tolerance. Consequently, we performed a comprehensive study of both hemodynamic and hormone responses to HVE. Twenty-two patients who underwent liver resection for secondary tumors developed in noncirrhotic livers were prospectively studied. Heart rate, arterial blood pressure, pulmonary artery pressure, mixed venous saturation, cardiac output, and left ventricular dimensions determined by transesophageal echocardiography were monitored in HVE patients. Blood concentrations of arginine vasopressin (AVP), epinephrine, norepinephrine, dopamine, and atrial natriuretic peptide and plasma renin activity (PRA) were measured before clamping; 5, 15, and 30 min after clamping; and 15 min after unclamping. Hemodynamic response to HVE was characterized by a significant (P < 0.05) decrease in left ventricular dimensions, fractional area change, and pulmonary artery pressure. We also observed a marked decrease in cardiac output (50%) and an increase in heart rate and systemic vascular resistance. After unclamping, there was peripheral vasodilation, assessed by a significant decrease in systemic vascular resistance from the preclamping value to unclamping. An acute and sustained increase in AVP and norepinephrine that returned to baseline after unclamping and the absence of modification in PRA concentrations were noted. The marked decrease in venous return that characterizes HVE is compensated for by an increase in vascular resistance secondary to an important activation of the AVP and sympathetic systems. The PRA system does not play an important role in maintaining arterial blood pressure during HVE.

IMPLICATIONS: Hemodynamic and hormonal responses to the acute interruption of caval venous return to the heart were investigated in patients undergoing liver resection with hepatic vascular exclusion. A compensatory role for arginine vasopressin and sympathetic systems that provoked increased vascular resistance was demonstrated.






Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press
Copyright © 2002 by the International Anesthesia Research Society.