Chadha Ryan, Patel Dhupal, Bhangui Pooja, Blasi Annabel, Xia Victor, Parotto Matteo, Wray Christopher, Findlay James, Spiro Michael, Raptis Dimitri Aristotle
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, USA.
Department of Anesthesia and Intensive Care Medicine, Addenbrooke's Hospital, Cambridge, UK.
Clin Transplant. 2022 Oct;36(10):e14613. doi: 10.1111/ctr.14613. Epub 2022 Feb 28.
In the era of enhanced recovery after surgery, there is significant discussion regarding the impact of intraoperative anesthetic management on short-term outcomes following liver transplantation (LT), with no clear consensus in the literature.
To identify whether or not intraoperative anesthetic management affects short-term outcomes after liver transplantation.
Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.
A systematic review following PRISMA guidelines was undertaken. The systematic review was registered on PROSPERO (CRD42021239758). An international expert panel made recommendations for clinical practice using the GRADE approach.
After screening, 14 studies were eligible for inclusion in this systematic review. Six were prospective randomized clinical trials, three were prospective nonrandomized clinical trials, and five were retrospective studies. These manuscripts were reviewed to look at five questions regarding anesthetic care and its impact on short term outcomes following liver transplant. After review of the literature, the quality of evidence according to the following outcomes was as follows: intraoperative and postoperative morbidity and mortality (low), early allograft dysfunction (low), and hospital and ICU length of stay (moderate).
For optimal short term outcomes after liver transplantation, the panel recommends the use of volatile anesthetics in preference to total intravenous anesthesia (TIVA) (Level of Evidence: Very low; Strength of Recommendation: Weak) and minimum alveolar concentration (MAC) versus bispectral index (BIS) for depth of anesthesia monitoring (Level of Evidence: Very low; Strength of Recommendation: Weak). Regarding ventilation and oxygenation, the panel recommends a restrictive oxygenation strategy targeting a PaO of 70-120 mmHg (10-14 kPa), a tidal volume of 6-8 ml/kg ideal body weight (IBW), administration of positive end expiratory pressure (PEEP) tailored to patient intraoperative physiology, and recruitment maneuvers. (Level of evidence: Very low; Strength of Recommendation: Strong). Finally, the panel recommends the routine use of antiemetic prophylaxis. (Level of evidence: low; Strength of Recommendation: Strong).
在术后加速康复时代，关于肝移植（LT）术中麻醉管理对短期预后的影响存在大量讨论，而文献中尚无明确共识。
确定术中麻醉管理是否会影响肝移植后的短期预后。
Ovid MEDLINE、Embase、Scopus、谷歌学术和Cochrane中心。
按照PRISMA指南进行系统评价。该系统评价已在PROSPERO（CRD42021239758）上注册。一个国际专家小组采用GRADE方法对临床实践提出建议。
筛选后，14项研究符合纳入本系统评价的标准。其中6项为前瞻性随机临床试验，3项为前瞻性非随机临床试验，5项为回顾性研究。对这些手稿进行了审查，以探讨关于麻醉护理及其对肝移植后短期预后影响的5个问题。查阅文献后，根据以下结果得出的证据质量如下：术中和术后发病率及死亡率（低）、早期移植物功能障碍（低）以及住院和重症监护病房住院时间（中等）。
为实现肝移植后的最佳短期预后，专家小组建议优先使用挥发性麻醉剂而非全静脉麻醉（TIVA）（证据级别：极低；推荐强度：弱），并建议使用最低肺泡浓度（MAC）而非脑电双频指数（BIS）进行麻醉深度监测（证据级别：极低；推荐强度：弱）。关于通气和氧合，专家小组建议采用限制性氧合策略，目标是动脉血氧分压（PaO）为70 - 120 mmHg（10 - 14 kPa），潮气量为6 - 8 ml/kg理想体重（IBW），根据患者术中生理情况调整呼气末正压（PEEP）并进行肺复张手法（证据级别：极低；推荐强度：强）。最后，专家小组建议常规使用预防性止吐药（证据级别：低；推荐强度：强）。
