EASL-EORTC clinical practice guidelines : management of hepatocellular carcinoma

Propofol is an intravenous sedative hypnotic agent which rapidly and reliably causes loss of consciousness. It is also associated with a quick and 'smooth' recovery, which distinguishes it from many of the more traditional anaesthetic regimens. Like other intravenous agents, propofol is both a cardiovascular and a respiratory depressant; however, the risk of these effects can be lessened by appropriate dosage adjustment or patient management. Anaphylaxis with propofol is rare. Propofol anaesthesia in day case surgery is consistently associated with a quicker early recovery than other intravenous agents and the more traditional anaesthetic regimens. Savings in time to discharge were more variable compared with these regimens, although propofol was commonly associated with less post-operative nausea and vomiting in this period. In the future, the relative benefits of propofol compared with the newer volatile agents (desflurane and sevoflurane) and propofol/volatile agent combinations need to be examined in this clinical setting. There is now clinical experience with propofol in major surgical procedures including cardiac and neurosurgery. Propofol has also been investigated as a sedative accompanying regional or local anaesthesia for diagnostic and therapeutic procedures, and in other clinical settings (ophthalmic surgery, cardioversion and electroconvulsive therapy). The unique antiemetic, antiepileptic and antipruritic effects of propofol may further broaden its appeal. As a result of its favourable recovery profile, propofol holds a central place in day case surgery anaesthesia. Accumulating clinical experience in cardiac and neurosurgery suggests that the full potential of propofol has yet to be realised.

Propofol. An update of its use in anaesthesia and conscious sedation.

Liver metastasis is the commonest form of distant metastasis in colorectal cancer. Selection criteria for surgery and liver-directed therapies have recently been extended. However, resectability remains poorly defined. Tumour biology is increasingly recognized as an important prognostic factor; hence molecular profiling has a growing role in risk stratification and management planning. Surgical resection is the only treatment modality for curative intent. The most appropriate surgical approach is yet to be established. The primary cancer and the hepatic metastasis can be removed simultaneously or in a two-step approach; these two strategies have comparable long-term outcomes. For patients with a limited future liver remnant, portal vein embolization, combined ablation and resection, and associating liver partition and portal vein ligation for staged hepatectomy have been advocated, and each has their pros and cons. The role of neoadjuvant and adjuvant chemotherapy is still debated. Targeted biological agents and loco-regional therapies (thermal ablation, intra-arterial chemo- or radio-embolization, and stereotactic radiotherapy) further improve the already favourable results. The recent debate about offering liver transplantation to highly selected patients needs validation from large clinical trials. Evidence-based protocols are missing, and therefore optimal management of hepatic metastasis should be personalized and determined by a multi-disciplinary team.

Colorectal liver metastases: An update on multidisciplinary approach.

https://flore.unifi.it/bitstream/2158/1100913/1/1-s2.0-S1590865816307770-main.pdf

Consensus conference on TIPS management: Techniques, indications, contraindications.

Radiation-Induced Liver Disease and Modern Radiotherapy.

Indocyanine green (ICG) kinetics (PDR/R15) used to quantitatively assess hepatic function in the perioperative period of major resective surgery and liver transplantation have been the object of an extensive, updated and critical review. New, non invasive bedside monitors (pulse dye densitometry technology) make this opportunity widely available in clinical practice. After having reviewed basic concepts of hepatic clearance, we analysed the most common indications ICG kinetic parameters have nowadays in clinical practice, focusing in particular on the diagnostic and prognostic role of PDR and R15 in the perioperative period of major liver surgery and liver transplantation. As recently pointed out, even if of extreme interest, ICG clearance parameters have still some limitations, to be considered when using these tests.

Indocyanine green kinetics to assess liver function: Ready for a clinical dynamic assessment in major liver surgery?

Antithrombin III supplementation during orthotopic liver transplantation in cirrhotic patients: a randomized trial.

TIPS is a percutaneous procedure which diverts blood from the portal to the systemic circulation preventing rebleeding from varices and stopping or reducing the formation of ascites. The choice of the anaesthetic technique is still a matter of debate. Since January 2003, 150 consecutive TIPS were performed using total intravenous anesthesia (TIVA), (propofol/fentanyl or remifentanil), endotracheal intubation and mechanical ventilation. Sixty-one patients were classified as ASA 2, 73 ASA 3, and 16 ASA 4. According to CHILD classification, 96 patients were in Class A, 48 in Class B, 6 in Class C. Mean duration f the procedure was 100+/-62 min. After TIPS placement Portal vein pressure decreased from 30+/-10 to 14+/-4 mmHg while RAP increased from 8+/-4 to 12+/-6 mmHg. Intraoperative fluid management included mainly crystalloids (750+/-200 ml, 5.4+/-1.5 ml/kg/h). Fresh frozen plasma (median 2 units, range 1-3) was given in 20 patients (13%) if PT INR was >2. Packed red cells (median 2 units, range 1-5) were transfused in 35 patients (23%) to keep haematocrit >25%; platelets were administered before the procedure if platelet count was <50,000x10(-9) (20 patients, 13%). Urine output was kept above 4 ml/kg/h with loops diuretics (mean diuresis 700+/-200 ml, 5+/-1.5 ml/kg/h). Ten patients (6.6%) required ICU after the procedure, because of intraoperative hemodynamic instability. Three patients (2%) died in the early postoperative period because of multiple organ failure associated with the acute deterioration of an already marginal hepatic function.

Transjugular intrahepatic portosystemic shunt (TIPS): the anesthesiological point of view after 150 procedures managed under total intravenous anesthesia

Study objective To define the pharmacokinetic profile of the induction dose of propofol in chronic renal failure patients. Design and setting Determination of propofol blood concentrations after the bolus dose of 2 mg.kg-1 bw injected in 30 seconds in a peripheral vein in a group of chronic renal failure (CRF) patients and in a group of normal patients (controls). Patients 10 CRF patients (7 males, 3 females, mean age 47 +/- 8 years old, mean body weight 66 +/- 8 kg) candidates to cadaveric renal transplantation and free from major hepatic diseases (study group); 8 ASA I patients (5 males, 3 females), without major cardiorespiratory, hepatic, renal, hematologic or metabolic diseases undergoing minor elective surgical procedures lasting from 50 to 90 minutes (control group). Measurements a) propofol blood concentrations by means of HPLC; b) derived pharmacokinetic parameters (calculated by means of Siphar, version 4.0, Societe de informatique medicale, Simed, Paris, 1991); c) cardiovascular parameters (heart rate, central venous pressure, invasive arterial pressure). Main results The decay of propofol whole blood concentrations, distribution, redistribution and elimination half lives were similar in CRF and in control patients. On the contrary, significantly different in CRF patients were propofol blood concentrations from two to ten minutes following the induction dose (lower), the area under concentration- time curve (AUC) (smaller), the mean resident time (longer), the total body clearance (greater), the volumes of distribution at steady state and during the elimination phase (larger). The larger volumes of distribution are closely correlated with the significantly lower albumin concentrations in the uremic patients. An accelerated hepatic biotransformation is one of the possible explanations for the greater total body clearance of propofol in the uraemic patients: in fact an increased glucuronyltrasferase activity and glucuronoconjugation induced by phenols has been demonstrated in uraemia. On the other hand, large volumes of distribution are often associated with elevated total body clearance. The only significant change in the cardiovascular profile was a reduction of 17 +/- 8% of the systolic blood pressure one minute after the administration of the induction dose of propofol, whereas heart rate, arterial and central venous pressures were rather stable after intubation and at skin incision: proper vascular filling before the induction of anaesthesia has probably played a crucial role in maintaining hemodynamic stability. Conclusions From the data gathered in this study, propofol can be considered a suitable anaesthetic agent for the induction of general anaesthesia in uraemic patients. In our opinion these data could constitute a basis for future protocols of total intravenous anaesthesia with propofol in uremic patients.

Pharmacokinetic profile of the induction dose of propofol in chronic renal failure patients undergoing renal transplantation.

Early severe infections after orthotopic liver transplantation.

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