0 g/dL (maximum of 3 L removed) and infused with a combination of albumin and crystalloid to restore isovolemia. Prospective randomized controlled studies demonstrate that it is safe and that ANH protected against allogeneic transfusions (22,28). As compared with standard volume management, Jarnagin et al. demonstrated that ANH resulted in fewer intraoperative transfusions (1.6% versus Inhibitors,research,lifescience,medical 10.4%, P=0.04). While interesting in concept, ANH is not routinely used in many centers at this time. We have not adopted
this strategy yet in our own practice. Blood loss-limiting surgical techniques Surgeons can take measures during hepatic parenchymal transection to further limit hemorrhage. These include temporary hepatic inflow occlusion (Pringle maneuver) and total vascular exclusion (TVE). These techniques are designed to isolate hepatic circulation (inflow and/or outflow) from the systemic circulation and minimize blood loss during dissection and Inhibitors,research,lifescience,medical transection of the hepatic http://www.selleckchem.com/products/chir-99021-ct99021-hcl.html parenchyma (Figure 1). A central Inhibitors,research,lifescience,medical tenet to the success of vascular exclusion is based on the premise that the liver (and
patient) is more tolerant to warm ischemia with reperfusion than to bleeding and the consequences of bleeding (e.g. transfusions.). Figure 1 Demonstration of potential sites of vascular occlusion. Pringle maneuver Originally performed for hepatic trauma, the Pringle maneuver is a straightforward way to minimizing blood loss during hepatectomy (47). A noncrushing clamp or a rumel tourniquet is placed around the structures in the porta hepatis to occlude
hepatic Inhibitors,research,lifescience,medical venous and arterial inflow during parenchymal transection. This can be performed in an intermittent or continuous manner with similar outcomes. It is recommended that the occlusion time be limited to an hour or less, as the ischemic insult will ultimately result in further hepatic parenchymal loss. After hepatic pedicle clamping with the Pringle, there is a 10% decrease in the cardiac index with a 40% increase in SVR and a 40% increase in mean arterial pressure (48-51). Inhibitors,research,lifescience,medical As compared with the previously mentioned occlusion techniques, the Pringle maneuver is relatively well-tolerated, but the anesthesiology staff should be continuously informed when it is applied because of the possibility of cardiac dysfunction and of air embolism, particularly if the hepatectomy is being done under low CVP. The potential sequela Brefeldin_A of air emboli, in the http://www.selleckchem.com/products/Bortezomib.html patient with a low CVP who may have an open hepatic vein, can be minimized by placing the patient in 15 degree Trendelenberg (24,25,52). The Pringle maneuver can be applied in a continuous or intermittent fashion. Many retrospective studies and prospective clinical trials have been performed examining the role and type of the Pringle maneuver, and its relationship to blood loss and reperfusion injury. Belghiti et al.