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CARDIOVASCULAR ANESTHESIA

Epidural Catheter and Increased Prothrombin Time After Right Lobe Hepatectomy for Living Donor Transplantation

Carl J. Borromeo, MD^*, Michael S. Stix, MD, PhD^*, Anne Lally, MD, and Elizabeth A. Pomfret, MD, PhD

Departments of *Anesthesiology and Hepatobiliary Surgery and Liver Transplantation, Lahey Clinic, Burlington, MA

Address correspondence and reprint requests to Carl J. Borromeo, MD, Department of Anesthesiology, Lahey Clinic, 41 Mall Road, Burlington, MA 01805. Address e-mail to carl.j.borromeo{at}lahey.org

	Abstract

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Implications: Donor right hepatic lobectomy for the purpose of living liver transplantation may be associated with postoperative abnormalities in tests of clotting function. This study explores the possible causes and anesthetic implications of this phenomenon.

	Introduction

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The number of adult patients requiring liver transplantation continues to exceed the available organ supply. Because of this disparity, the practice of living donor liver transplantation (LDLT) is being pursued in some institutions (1–3) and may become more common in the future. LDLT is already an accepted practice for pediatric end-stage liver disease (4,5) where donation of the smaller left lobe or left lateral segment provides adequate graft volume to meet the metabolic needs of the recipient. For an adult recipient, the donor must give the much larger right hepatic lobe, which involves an increased amount of blood loss as well as a greater physiologic insult. Donors for these cases subject themselves to greater physical risk, yet to be quantified. They also subject themselves to substantial postoperative pain from the bilateral subcostal incision. Our anesthetic management includes postoperative epidural pain relief. These epidural catheters have been very effective, but we have noticed a postoperative increase in prothrombin time (PT) in these patients, as the following case report describes.

	Case Report

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After extensive medical and psychological workup, a 37-yr old male (87 kg, 177 cm) presented to our institution for donor right hepatic lobectomy (DRL) for the purpose of his mother’s LDLT. The past medical history was significant for mild asthma and allergic rhinitis. His only medication was inhaled albuterol taken as needed (none in the last month). He had no known drug allergies and no prior surgeries. Physical examination revealed a healthy-appearing male with an arterial blood pressure of 124/86 mm Hg. His airway, heart, and lung examinations were normal. Preoperative values included a PT of 10.1 s (international normalized ratio [INR] 0.9), partial thromboplastin time of 25.2 s, and hematocrit of 39.7%. The patient had donated two units of autologous whole blood 3 wk before the operation.

An epidural catheter was placed at the T_7–8 interspace without evidence of paresthesia, blood, or cerebrospinal fluid. ASA standard plus invasive arterial and central venous pressure monitors were used during the case. A right hepatectomy (graft weight 1020 g) and cholecystectomy proceeded uneventfully under combined general (isoflurane, fentanyl 250 mcg, pancuronium 14 mg) and epidural (bupivacaine 0.5% at 5–8 mL/h) anesthesia. Duration of the operation was 8.25 h. Intraoperatively, blood pressures remained between 90/50 mm Hg and 120/70 mm Hg, central venous pressure 5–9 mm Hg, and urine output 50 mL/h (total 600 mL). Phenylephrine infusion was used intermittently to maintain acceptable blood pressures. Parenchymal dissection was performed without inflow occlusion. The patient received 5600 mL of crystalloid. Cell salvage totalled 800 mL and was processed with subsequent autotransfusion of one unit of washed packed red cells. It was not necessary to transfuse his predonated autologous blood.

The trachea was extubated at the end of the case, and the patient was transferred to the postanesthesia care unit. An epidural infusion of bupivacaine 0.1% was used for postoperative analgesia. Laboratory values obtained in the postanesthesia care unit included a hematocrit of 34.8%, a PT of 13.6 s (INR 1.2), and a partial thromboplastin time of 28.3 s.

Postoperative liver function tests are shown in Table 1. The PT peaked on the afternoon of postoperative day (POD) 1 at 19.2 s (INR 1.6) (20 h postoperatively) and normalized by the morning of POD 3 (PT 13.5, INR 1.1) (60 h postoperatively). He received satisfactory analgesia and did not demonstrate lower extremity motor or sensory deficits. The catheter was removed on POD 3 (PT 13.5, INR 1.1) and the patient was discharged home on POD 9 without complication.

	Discussion

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Major liver resection results in measurable decreases in levels of various clotting factors. This factor depletion is thought to be a result of consumption and half-life-dependent decay, as well as a transient synthetic insufficiency of the remnant liver. Studies in humans after liver resections have shown diminished levels of hepatically synthesized factors II, V, VII, IX, X (9–13), although the level of factor VIII, which is produced and stored in significant amounts outside the liver (6), remains unchanged (14). As a result, prolongation of the PT is a common finding after major hepatic resection. It has generally been accepted that massive transfusion (7,11,15), underlying liver disease (16,17), and extent of resection (7,9,16,17) contribute to the development of this coagulopathy. Other studies (9,15) suggest that the postoperative synthetic dysfunction may also be related to the duration of vascular occlusion (used to limit blood loss during parenchymal dissection).

DRL for the purpose of LDLT offers a unique opportunity to observe the effects of major hepatic resection on tests of coagulation without the confounding influences of underlying liver disease, inflow occlusion, and in most cases, massive transfusion. This case illustrates an increase in PT after DRL in a healthy donor. We have noticed similar responses in other donors for adult-adult LDLT. Figure 1 shows the PT after surgery in the first five DRLs performed at our institution, including the above case. It has been common for the PT to increase on POD 1 and to normalize in subsequent days. In Figure 2, the maximum postoperative PT for each patient is plotted against the fraction of liver resected for donation (donor graft mass divided by total liver mass as estimated by preoperative computed tomography scan). This figure illustrates a direct correlation between extent of resection and maximum postoperative PT.

View larger version (16K): [in this window] [in a new window]   Figure 1. Postoperative prolongation of the prothrombin time (PT) in five patients after donor right lobectomy. Values at time zero were the first measurements taken in the postanesthesia care unit. All patients had normal PT values preoperatively.

View larger version (10K): [in this window] [in a new window]   Figure 2. Extent of resection (ratio of graft mass to total liver mass) versus maximum prothrombin time (PT) for each patient.

There is evidence to suggest that disorders of hemostasis may occur after major hepatic resection, even without massive transfusion (9) or the development of disseminated intravascular coagulopathy (14,17). Results from our first five DRLs suggest that extent of resection is probably the most important factor in the resulting prolongation of the PT. In our experience, the PT returns to normal within 3–6 days. Transiently impaired hepatic synthesis may account for this imbalance in hemostatic mechanisms. The safe conduct of care for living liver donors must take into account the possibility of this phenomenon. Because of the variability between patients, the PT should be monitored postoperatively and checked before catheter removal. Frequent neurologic testing should also be done while the epidural catheter is in place and for several hours after its removal. Until this hemostatic abnormality is better understood, the anesthesiologist caring for patients undergoing DRL must weigh the risk of epidural hematoma formation against the benefits of epidural analgesia in this unique population. Further studies to characterize the hemostatic abnormalities after liver resection are warranted.

	References

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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