1. Transoesophageal Doppler Monitoring during Major Surgeries can Affect Anaesthesia Management Khaled Yassen MD FFARCSI

3. Anaesthesia Department Liver Institute, Menoufiya Since 1986 ٍ University

4. New Liver Institute 2015

5. Main Fields of Interest at Menoufiya University, Liver Institute, Egypt Liver Transplantation Liver resection Hepato-Pancreaticobiliar Surgery Intensive Care for Hepatic Patients Endoscopy Paediatric hepatic surgery ( Kassi procedure) General surgery for hepatic patients

6. No Conflict of Interest All the following research is funded by the Liver Institute, Anaesthesia Department funds AND Supported by the Liver Transplant Unit funds.

7. Transoesophageal Doppler

8. Transesophageal Doppler (TED) 1- Provides a continuous beat to beat waveform that is proportional to the left ventricular stroke volume. 2-Derives haemodynamic variables that may guide clinical management. 3- With each heart beat, the velocity of blood Flowing through the descending aorta detected and depicted as a velocity over time wave form.

9. Normal wave form

11. Intra-cardiac trac e. Venous trace. Coeliac artery trace Pulmonary artery trace Abnormal traces

12. Algorithm for fluid administration British Journal of Hospital Medicine, 2007

13. International Research Presentations of the Liver Institute Saudi Journal Anaesthesia July- September 2011Volume 5 (3 )241-356 Use of transesophageal Doppler as a sole cardiac output monitor for reperfusion hemodynamic changes during living donor liver transplantation: An observational study M Hussien, E Refaat, N Fayed, K Yassen, M Khalil, W Mourad POPULAR

14. Doppler Results in Liver Tx Helped to explain the transient hypotension that follows graft reperfusion -----Significant decrease in peripheral vascular resistance and not due to cardiac contractility depression. TED was found to help maintain fluid during management, which kept an adequate CVP. Further studies on a larger scale are still needed.

15. Conclusion TED as a sole monitor for COP was able to present significant and reliable changes in the cardiovascular status of the recipients which could help to guide fluid and drug supportive therapy in this population of patients. This preliminary study will need to be applied on a large scale.

16. 5200 Viewer Popular Article Use of transesophageal Doppler as a sole cardiac output monitor for reperfusion hemodynamic changes during living donor liver transplantation: An observational study M Hussien, E Refaat, N Fayed, K Yassen, M Khalil, W Mourad July-September 2011, 5(3):264-269 DOI:10.4103/1658-354X.84099 PMID:21957404 [ABSTRACT] [FULL TEXT] [PDF] [Mobile Full text] [EPub] [PubMed] [ABSTRACT][FULL TEXT][PDF][Mobile Full text][EPub][PubMed] 5200 viewer 650 Downloaded

17. 2012

18. Liver Resection Associated by hepatocellular derangements, metabolic, haemodynamic, coagulation and electrolyte changes due to temporary liver dysfunction.

23. Paris Transesophageal Doppler as a haemodynamic monitor during and after liver resection for cirrhotic patients. An observational study Yassen K, El Sharkawy O, Ibraheem A.E, Refaat E, Mahdy W, Fayed N. Liver Institute Menoufiya University, Department of Anaesthesiology and Intensive Care, Sheeben El Kom, Egypt Accepted 24 March 2013 Saudi Journal Anaesthesia

24. Transesophageal Doppler Intraoperative haemodynamic changes during and after liver resection in cirrhotics. Abd ElHafez H Box and whisker plots graph shows cop (cardiac output) changes

25. Transesophageal Doppler Intraoperative haemodynamic changes during and after liver resection in cirrhotics. Abd ElHafez H SVR(systemic vascular resistance) changes in Doppler group

27. P < 0.05 for colloids Reduced Colloids consumption when guided with FTc ( Corrected flow time)

28. Postoperative complications and hospital stay P value <0.05 * * *

29. TED was able to: 1- Detect Significant increase in COP, CI and SV immediately after liver resection 2- Significant reduction in SVR after liver resection and during the early postoperative period. 3-Optimize intraoperative fluid consumption. 4- Decrease postoperative complication and shortened the hospital stay.

30. 5-Minimal skills were needed for insertion and interpretation, no reported complications from the process of monitoring. 6-The current algorithm failed to lower CVP to below 5 cmH2O during resection phase.

32. 1- Haemodynamic monitoring during liver resection is essential. 2-Optimization of intraoperative fluid 3-TED is a valuable tool for intraoperative monitoring 4-A future larger study to adjust the rate of fluid administration is needed in such category of patients and to study CVP and FTc relationship.

33. TCI Propofol/Fentanyl vs Desflurane for liver resection in cirrhotics

34. Cochran Registration

35. Desflurane

36. Patient State Index (PSI) ( Brain function monitoring) A newly processed EEG parameter that measures the direct effects of sedatives on the brain Provides objective information about a patient’s response to sedation Numerical scale correlates to sedation endpoints Optimizes sedation assessment and titration

37. The PSI sensor 4 active leads

38. Guidelines for the PSI

39. Of

41. Figure 1. Figure 2.

42. Figure 3. Figure 4.

43. Recommendations. Desfurane is more appropriate than TCI propofol fentanyl from haemodynamics. Both techniques can be used safely for liver surgery in cirrhotics. Close CVS monitoring is recommended in liver surgery. TED is reliable and minimally invasive monitor.

44. Poster presentation ESA 2014

45. Published in Anaesthesia and Clinical research vol 5, issue 12 2015

47. Alexandria Biblothetica

48. Thank You