title: Hypertonic saline solution increases cerebral perfusion pressure during clinical orthotopic liver transplantation for fulminant hepatic failure: preliminary results.
abstract: During orthotopic liver transplantation for fulminant hepatic failure, some patients may develop sudden deterioration of cerebral perfusion and oxygenation, mainly due to increased intracranial pressure and hypotension, which are likely responsible for postoperative neurological morbidity and mortality. In the present study, we hypothesized that the favorable effects of hypertonic saline solution (NaCl 7.5%, 4 mL/kg) infusion on both systemic and cerebral hemodynamics, demonstrated in laboratory and clinical settings of intracranial hypertension and hemorrhagic shock resuscitation, may attenuate the decrease in cerebral perfusion pressure that often occurs during orthotopic liver transplantation for fulminant hepatic failure.
  
  
  METHODS
  10 patients with fulminant hepatic failure in grade IV encephalopathy undergoing orthotopic liver transplantation with intracranial pressure monitoring were included in this study. The effect on cerebral and systemic hemodynamics in 3 patients who received hypertonic saline solution during anhepatic phase (HSS group) was examined, comparing their data with historical controls obtained from surgical procedure recordings in 7 patients (Control group). The maximal intracranial pressure and the corresponding mean arterial pressure values were collected in 4 time periods: (T1) the last 10 min of the dissection phase, (T2) the first 10 minutes at the beginning of anhepatic phase, (T3) at the end of the anhepatic phase, and (T4) the first 5 minutes after graft reperfusion.
  
  
  RESULTS
  Immediately after hypertonic saline solution infusion, intracranial pressure decreased 50.4%. During the first 5 min of reperfusion, the intracranial pressure remained stable in the HSS group, and all these patients presented an intracranial pressure lower than 20 mm Hg, while in the Control group, the intracranial pressure increased 46.5% (P < 0.001). The HSS group was the most hemodynamically stable; the mean arterial pressure during the first 5 min of reperfusion increased 21.1% in the HSS group and decreased 11.1% in the Control group (P < 0.001). During the first 5 min of reperfusion, cerebral perfusion pressure increased 28.3% in the HSS group while in the Control group the cerebral perfusion pressure decreased 28.5% (P < 0.001). Serum sodium at the end of the anhepatic phase and 3 hours after reperfusion was significantly higher in the HSS group (153.00 +/- 2.66 and 149.00 +/- 1.73 mEq/L) than in the Control group (143.71 +/- 3.30 and 142.43 +/- 1.72 mEq/L), P = 0.003 and P < 0.001 respectively.
  
  
  CONCLUSIONS
  Hypertonic saline solution can be successfully used as an adjunct in the neuroprotective strategy during orthotopic liver transplantation for fulminant hepatic failure, reducing intracranial pressure while restoring arterial blood pressure, promoting sustained increase in the cerebral perfusion pressure.
authors.affiliation: Hospital das Clínicas, São Paulo University Medical School, Brazil. joel.net@globo.com
authors.forename: Joel Avancini Rocha
authors.initials: JA
authors.lastname: Filho
authors.forename: Marcel Autran C
authors.initials: MA
authors.lastname: Machado
authors.forename: Ricardo Souza
authors.initials: RS
authors.lastname: Nani
authors.forename: João Plínio S
authors.initials: JP
authors.lastname: Rocha
authors.forename: Estela R R
authors.initials: ER
authors.lastname: Figueira
authors.forename: Telesforo
authors.initials: T
authors.lastname: Bacchella
authors.forename: Maurício
authors.initials: M
authors.lastname: Rocha-e-Silva
authors.forename: José Otávio C
authors.initials: JO
authors.lastname: Auler
authors.forename: Marcel C C
authors.initials: MC
authors.lastname: Machado
mesh_terms: D001921:Brain / Q000098:blood supply*; D016022:Case-Control Studies; D005440:Fluid Therapy; D006501:Hepatic Encephalopathy / Q000188:drug therapy* / Q000209:etiology; D006801:Humans; D007427:Intracranial Pressure / Q000187:drug effects*; D017114:Liver Failure, Acute / Q000150:complications* / Q000601:surgery*; D016031:Liver Transplantation; D015424:Reperfusion; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use*; D012720:Severity of Illness Index
chemical_list: D012462:Saline Solution, Hypertonic