Liver Transplantation Clinical Trial
Official title:
Non-Invasive Assessment of Cerebral Blood Flow Autoregulation in Patients Undergoing Liver Transplantation
Patients with liver failure undergoing liver transplantation often have clinical or sub-clinical encephalopathy that may lead to increased intracranial pressure. The latter may lead to abnormal regulation of blood flow to the brain (cerebral autoregulation) complicating patient management during and after general anesthesia. The current methods for monitoring for elevated intracranial pressure are invasive and, thus, limited to severe encephalopathy. In this study the investigators will evaluate the potential utility of monitoring cerebral blood flow (CBF) autoregulation non-invasively using near infra-red spectroscopy in patients undergoing liver transplantation.
Hepatic encephalopathy complicating chronic liver failure in patients undergoing liver
transplantation increases the risk for adverse outcomes including mortality. Even mild
hepatic encephalopathy may not be recognized clinically without specific testing but can be
associated with impaired functional status and reduced quality of life before liver
transplantation. The changes that can be seen in chronic liver failure, (cerebral edema and
increased intracranial pressure) can adversely affect cerebral blood flow autoregulation that
may predispose to brain injury during the multiple hemodynamic perturbations that occur
during and after liver transplantation. Currently, invasive monitoring with an intracranial
"bolt" is the only method to aggressively manage patients with elevated intracranial pressure
from acute liver failure and hepatic encephalopathy. The placement of an intracranial
pressure catheter in patient with liver failure is associated with a risk of brain hemorrhage
due the presence of a coagulopathy. Further, the risk of this type of monitoring outweighs
the benefits in the patients with milder or subclinical forms of hepatic encephalopathy. In
this pilot study of 20 patients undergoing liver transplantation the investigators will
evaluate the feasibility of non-invasive monitoring of CBF autoregulation and assess whether
autoregulation is impaired in this group of patients. The investigators hypothesize that
cerebral blood flow autoregulation is impaired in patients undergoing liver transplantation
based on severity of liver disease. In this situation, improved patient monitoring would
allow clinicians to maintain arterial blood pressure above an individual's lower limit of
cerebral blood flow autoregulation that might prevent devastating brain injury during and
after surgery. Cerebral blood flow autoregulation can be continuously monitored by evaluating
the correlation coefficient between cerebral blood flow velocity measured with transcranial
Doppler and arterial blood pressure. The investigators have developed a novel method of
autoregulation monitoring using near infrared spectroscopy that allows continuous monitoring
of autoregulation with the cerebral oximetry index and the hemoglobin volume index(, a moving
linear correlation coefficient between cortical tissue oxygen saturation and hemoglobin level
with arterial blood pressure, respectively. The latter approach is more practical and would
allow widespread autoregulation monitoring in diverse clinical settings. A secondary
hypothesis of this study is that near infrared spectroscopy-based monitoring of CBF
autoregulation will provide an accurate assessment of the limits of autoregulation compared
with the more clinically challenging transcranial Doppler methods .
Specific Aims:
1. To assess whether patients undergoing liver transplantation have impaired cerebral blood
flow autoregulation.
2. To evaluate whether non-invasive monitoring of cerebral blood flow autoregulation with
cerebral oximetry index and hemoglobin volume index can identify the lower limit of
autoregulation within 10 mmHg compared with that measured with transcranial Doppler.
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