Morkane Clare M, Sapisochin Gonzalo, Mukhtar Ahmed M, Reyntjens Koen M E M, Wagener Gebhard, Spiro Michael, Raptis Dimitri A, Klinck John R
Department of Intensive Care Medicine, Kings College Hospital, London, UK.
Multio-Organ Transplant & HPB Surgical Oncology, Division of General Surgery, University Health Network, University of Toronto, Toronto, Canada.
Clin Transplant. 2022 Oct;36(10):e14651. doi: 10.1111/ctr.14651.
Fluid management practices during and after liver transplantation vary widely among centers despite better understanding of the pathophysiology of end-stage liver disease and of the effects of commonly used fluids. This reflects a lack of high quality trials in this setting, but also provides a rationale for both systematic review of all relevant studies in liver recipients and evaluation of new evidence from closely related domains, including hepatology, non-transplant abdominal surgery, and critical care.
To develop evidence-based recommendations for perioperative fluid management to optimize immediate and short-term outcomes following liver transplantation.
Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central.
Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Studies included those evaluating the following postoperative outcomes: acute kidney injury, respiratory complications, operative blood loss/red cell units required, and intensive care length of stay. PROSPERO protocol ID: CRD42021241392 RESULTS: Following expert panel review, 18 of 1624 screened studies met eligibility criteria for inclusion in the final quantitative synthesis. These included six single center RCTs, 11 single center observational studies, and one observational study comparing centers with different fluid management techniques. Definitions of interventions and outcomes varied between studies. Recommendations are therefore based substantially on expert opinion and evidence from other clinical settings.
A moderately restrictive or "replacement only" fluid regime is recommended, especially during the dissection phase of the transplant procedure. Sustained hypervolemia, based on absence of fluid responsiveness, elevated filling pressures and/or echocardiographic findings, should be avoided (Quality of Evidence: Moderate | Grade of Recommendation: Weak for restrictive fluid regime. Strong for avoidance of hypervolemia). Mean Arterial Pressure (MAP) should be maintained at >60-65 mmHg in all cases (Quality of Evidence: Low | Grade of Recommendation: Strong). There is insufficient evidence in this population to support preferential use of any specific colloid or crystalloid for routine volume replacement. However, we recommend against the use of 130/.4 HES given the high incidence of AKI in this population.
尽管对终末期肝病的病理生理学以及常用液体的作用有了更好的理解，但肝移植期间及术后的液体管理方法在各中心之间仍存在很大差异。这既反映了在这种情况下缺乏高质量的试验，也为系统回顾肝移植受者的所有相关研究以及评估来自密切相关领域（包括肝病学、非移植腹部手术和重症监护）的新证据提供了依据。
制定基于证据的围手术期液体管理建议，以优化肝移植后的近期和短期结果。
Ovid MEDLINE、Embase、Scopus、谷歌学术和Cochrane中心。
按照PRISMA指南进行系统回顾，并采用源自国际专家小组的GRADE方法提出建议。纳入的研究包括评估以下术后结果的研究：急性肾损伤、呼吸并发症、手术失血量/所需红细胞单位以及重症监护住院时间。PROSPERO方案编号：CRD42021241392 结果：经过专家小组审查，1624项筛选研究中有18项符合纳入最终定量综合分析的资格标准。其中包括6项单中心随机对照试验、11项单中心观察性研究以及1项比较不同液体管理技术中心的观察性研究。不同研究之间干预措施和结果的定义各不相同。因此，建议主要基于专家意见和其他临床环境的证据。
建议采用适度限制性或“仅补充”的液体方案，尤其是在移植手术的解剖阶段。应避免基于无液体反应性、充盈压升高和/或超声心动图结果的持续性高血容量（证据质量：中等 | 推荐等级：限制性液体方案为弱推荐。避免高血容量为强推荐）。所有情况下平均动脉压（MAP）应维持在>60 - 65 mmHg（证据质量：低 | 推荐等级：强推荐）。在该人群中，没有足够的证据支持优先使用任何特定的胶体或晶体进行常规容量替代。然而，鉴于该人群中急性肾损伤的高发生率，我们不建议使用130/0.4羟乙基淀粉。
