Huang, Hock-Liew Eng, King-Wah Chiu, Shih-Hor Wang, Chih-Che Lin,
Tsan-Shiun Lin, Yueh-Wei Liu, Bruno Jawan
Kwok-Wai Cheng, Chao-Long Chen, Yu-Fan
Cheng, Chia-Chih Tseng, Chih-Hsien Wang, Yaw-Sen Chen, Chih-Chi
Wang, Tung-Liang Huang, Hock-Liew Eng, King-Wah Chiu, Shih-Hor Wang,
Chih-Che Lin, Tsan-Shiun Lin, Yueh-Wei Liu, Bruno Jawan,
Department of Anesthesiology and Liver Transplantation Program,
Chang Gung Memorial Hospital, Kaohsiung Medical Center, Taiwan China
Chang Gung University, Ta-pei, Taiwan, China
Correspondence to: Bruno Jawan MD, Department of
Anesthesiology, Chang Gung Memorial Hospital Ta-Pei Rd. 123, Niao
Shung Hsiang, Kaohsiung, Taiwan, China.
commonly seen in liver transplantation (LT) has often been
attributed to the dextrose in the storage solution of blood
transfusion products. The purpose of the study is to compare the
changes of the blood glucose levels in transfused and non-transfused
patients during LT.
retrospective study on 60 biliary pediatric patients and 16 adult
patients undergoing LT was carried out. Transfused pediatric
patients were included in Group I (GI), those not transfused in
Group II (GII). Twelve adult patients were not given transfusion and
assigned to Group III (GIII); whereas, four adult patients who
received massive transfusion were assigned to Group IV (GIV). The
blood glucose levels, volume of blood transfused, and the volume of
crystalloid infused were recorded, compared and analyzed.
Results showed that the changes in blood glucose levels during LT
for both non-transfused and minimally transfused pediatric groups
and non-transfused and massively-transfused adult groups were almost
conclude that blood transfusion does not cause significant changes
in the blood glucose levels in this study.
© 2005 The WJG Press and Elsevier Inc. All rights reserved.
Key words: Organ; Liver surgery; Transplantation; Anesthesia;
General monitoring; Blood glucose transfusion; Bank blood component;
Infusion; 5% dextrose in 1/4 saline
Cheng KW, Chen CL, Cheng
YF, Tseng CC, Wang CH, Chen YS, Wang CC, Huang TL, Eng HL, Chiu KW,
Wang SH, Lin CC, Lin TS, Liu YW, Jawan B. Dextrose in the banked
blood products does not seem to affect the blood glucose levels in
patients undergoing liver transplantation. World J Gastroenterol
2005; 11(18): 2789-2791
Contrary to earlier reports,
hyperglycemia during liver transplantation (LT) is a common finding[2-4].
Normal blood glucose levels could even be maintained during LT
procedure in humans
with blood as the only source of dextrose. The mechanism is
attributed to blood transfusion, which contains dextrose as part of
the storage solution[2,3].
Blood transfusion in LT was once a common feature in the past,
however, with increasing LT experience, the blood loss and
subsequent blood and blood product replacement during operations
have decreased gradually[6,7].
LT can now be performed without pack blood cell
and fresh frozen plasma.
In our living donor LT setting, some patients do not receive any
banked blood products
but hyperglycemia is still noted. Therefore, we hypothesize that
hyperglycemia seen in LT might not be related to blood transfusion.
In this study, blood glucose levels of pediatric patients with
biliary atresia undergoing LT with or without blood transfusion and
four massively-transfused adult patients vs 14 non-transfused
adult patients were compared and analyzed.
MATERIALS AND METHODS
The approval of the Ethics Committee of the Department of Health,
Taiwan, was obtained and written informed consent for anesthesia and
surgery were also obtained from the adult patients or the parents of
the pediatric patients. Sixty biliary pediatric patients who
underwent living donor liver transplantation (LDLT) and 16 adult LT
patients at Chang Gung Memorial Hospital, Kaohsiung Medical Center
from January 1999 to April 2002 were included. The anesthesia
records were analyzed retrospectively. The pediatric patients were
grouped as transfused (GI) and non-transfused (GII) group. Since the
transfusion of GI was minimal, an additional four adults in our
cadaveric series, who were massively transfused over 10 L of blood
products (GIV) were compared with 12 of our 28 adult LDLT patients
(G III) who did not receive blood transfusion. Anesthesia for all
patients was maintained with isoflurane in an oxygen-air mixture.
Fentanyl was given whenever necessary and atracurium was used as
muscle relaxant. Continuous monitoring with ECG, pulse oximetry,
arterial blood pressure, central venous pressure, end tidal CO2,
urine output and naso-pharyngeal temperature was performed. At least
four intravenous lines were set for fluids and blood replacements.
Crystalloids such as normal saline, half saline, lactated Ringer,
dextrose 5% in 1/4 saline were used. Five percent albumin and
crystalloids instead of blood products were used to replace blood,
ascites and transudate losses to maintain a state of normovolemia.
Transfusion threshold was set at hemoglobin of 6-7 g/dL for as long
as the patients remained hemodynamically stable. The amount of
packed RBC (preserved in CPDA-1) transfused was estimated to reach a
Hb of no greater than 8-9 g/dL after transfusion. LDLT without veno-venous
bypass was performed as reported previously[11,12].
Continuous intravenous dopamine infusion was given at a rate of 2 µg/(kg·h)
throughout the operation. Arterial blood gases and blood sugar were
recorded after induction of the anesthesia, every 2 h during liver
dissection, at anhepatic phase, 10 min after reperfusion and at the
end of the operation. Blood glucose levels, total amount of fluids
and blood components (including crystalloids with or without 5%
dextrose, 5% albumin, packed red cell and fresh frozen plasma) were
recorded. Blood glucose levels were compared between the transfused
and non-transfused pediatric patients; likewise, comparison between
the non-transfused adult patients and massively-transfused adult
patients was made. Measurements between groups were compared using
Mann-Whitney U test. All the data were given in mean±SD.
Statistical calculations were performed using the SPSS advanced
statistics module (SPSS Inc, Chicago, IL, USA). P<0.05 was
regarded as significant.
Thirty-eight patients were included in the transfused group (GI),
while twenty-two patients were included in the non-transfused group
(GII). Table 1 shows the characteristics of the patients of GI and
GII. The age, weight, height of the patients and anesthesia duration
were not significantly different between groups. Higher hemoglobin
levels were observed in GII. More intraoperative blood loss
requiring packed blood cells and fresh frozen plasma transfusion was
noted among GI patients. There was no difference between the two
pediatric groups with regard to the mean amount of crystalloids with
or without 5% dextrose and 5% albumin given. Mean urine output
measured in pediatric groups showed no statistical difference. Blood
glucose levels in both groups were almost the same with a tendency
towards hyperglycemia at 170-270 mg/dL(Figure 1). The changes in
blood glucose levels in the four massively-transfused adult patients
(with 8 020±6 544 mL red blood cells and 4 085±2 888 mL fresh
frozen plasma) were similar to the changes seen in the GIII patients
Figure 1 (PDF)
changes of blood glucose level between groups during LT in biliary
atresia patients with and without blood transfusion.
(PDF) No significant changes of blood glucose level between
groups during LT in adult patients with and without blood
Table 1 Patients’ characteristics
between pediatric groups
(n = 38)
(n = 22)
|Preoperative Hb (mg%)
|Postoperative Hb (mg%)
The liver plays an important role in carbohydrate metabolism and
glucose homeostasis. Impaired gluconeogenesis and glucogenolysis,
glucose intolerance or insulin resistance may occur in patients with
end stage liver disease, predisposing these patients to fasting
hypoglycemia or postprandial hyperglycemia[13-17].
In view of the complexity of glucose regulation and disease-specific
our study primarily focuses on pediatric biliary atresia patients,
who have had Kasai operation. This specific group of patients
represents children of the same age group in a similar physiological
state with the same disease entity. Figure 1 shows that the blood
glucose increased significantly 2 h after induction of anesthesia
from 108±46 to 174±60 and 92±22 to 185±73 mg/dL for GI and GII,
respectively. Likewise, Figure 2 shows the similar changes of the
blood glucose for GIII and GIV patients. The levels of the blood
glucose for all groups remained lightly hyperglycemic until the end
of the operation regardless of transfusion.
The volume of blood transfused in GI was
statistically significant but the amount of the dextrose contained
in the 272 mL of transfused blood products may be clinically
irrelevant when compared to GII. We find that the volume of blood
transfused is not related to blood glucose level in the four
massively-transfused adult patients given over 10 L blood components
during LT (Table 2). The fresh blood stored in CPDA-1 contained
dextrose of 432 mg/dL. This decreases to 282 mg/dL after 35 storage.
Blood that is massively lost also contain dextrose. Blood glucose
levels will not change despite exogenous dextrose loading if the
amount of blood loss is greater than the volume transfused. This may
explain why over 10 L of blood products given to GIV patients did
not cause significant increase in blood glucose compared to GIII
patients. Although Hb in blood product is usually higher than anemic
patients requiring blood transfusion, the above mechanism may also
explain why there is little increase in Hb level in patients
receiving blood transfusion during massive bleeding in which losses
are greater than that replaced. The preoperative and postope-rative
Hb showed that none of our patients was over-transfused (Table 1).
It indicates that hyperglycemia encountered during LT in all groups
is not related to blood transfusion per se. This observation is
shared by other authors.
Hyperglycemia is probably caused by stress during LT surgery and
from two of methyl-prednisolone given during the operation. Both
noxious stimuli and methyl-prednisolone are known to increase blood
Furthermore, extrahepatic gluconiogenesis
and sudden release of glucose from the grafted liver in the
reperfusion phase may also cause hypergl-ycemia.
Recent discoveries reveal that extrahepatic gluconi-ogenesis during
anhepatic phase, most notably by the kidneys, contributes to
endogenous glucose production in humans.
This endogenous glucose production is sufficient to maintain normal
blood glucose levels in the anhepatic phase of orthotopic LT.
Corollary, reperfusion is usually associated with a sudden increase
of blood glucose as a result of massive glucose release from the
graft liver as seen in very high glucose levels in hepatic venous
blood compared to arterial blood.
Table 2 Patients’
characteristics between adult groups
(n = 12)
(n = 4)
Hypo- as well as severe hyperglycemia should be
avoided during surgery especially in LT. Our results showed that
blood glucose levels of 170-270 mg/dL could be maintained with
minimal administration of 499±279 or 367±209 mL 5% dextrose
solution or 2.7 and 2 mg/(kg·min) for transfused and non-transfused
pediatric patients, respectively. The doses are only one-third to
half of the recommended doses (4-6 mg/(kg·min)) in routine
non-liver transplant pediatric surgery. We conclude that no
significant changes occur in the blood glucose levels among
minimally-transfused and non-transfused, as well as in
non-transfused and massively-transfused, patients undergoing LT.
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