High End-Surgery Arterial Lactate Concentration (ES-ALC) predicts poor outcome after hepatectomy. The aim of this study was to identify intraoperative hemodynamic parameters predicting high ES-ALC during elective liver resection. Patients who underwent liver resection between 2017 and 2018, under FloTrac/EV1000^TM hemodynamic monitoring, were included. The ES-ALC cutoff best predicting severe postoperative complications was identified. Association between high ES-ALC and preoperative and intraoperative variables was assessed. 108 patients were included; 90-day mortality was 0.9% and severe morbidity 14.8%. ES-ALC cutoff best discriminating severe complications was 5.05 mmol/L. Patients with ES-ALC > 5.0 mmol/L had a relative risk of severe complications of 2.8% (p = 0.004). High ES-ALC patients had longer surgery and ischemia duration, larger blood losses and higher requirements of fluids and blood transfusions. During surgery, hemoglobin concentration and oxygen delivery (DO₂) decreased more significantly in patients with high ES-ALC, although they had similar values of stroke volume and cardiac output to those of other patients. At multivariate analysis, surgery duration and lowest recorded DO₂ value were the strongest predictors of high ES-ALC. ES-ALC > 5.0 mmol/L in elective liver resection predicts postoperative morbidity and is essentially driven by the impaired DO_2. Timely correction of blood losses might prevent the ES-ALC increase.

Intensive Care Unit (ICU)-Acquired Weakness (ICU-AW) is a generalized muscle weakness that is clinically detected in critical patients and has no plausible etiology other than critical illness. ICU-AW is uncommon in patients undergoing orthotopic liver transplantation (OLT). Our report sheds light on the highest number of ICU-AW cases observed in a single center on OLT patients with early allograft dysfunction. Out of 282 patients who underwent OLT from January 2015 to June 2023, 7 (2.5%) developed generalized muscle weakness in the ICU and underwent neurophysiological investigations. The neurologic examination showed preserved extraocular, flaccid quadriplegia with the absence of deep tendon reflexes in all patients. Neurophysiological studies, including electromyography and nerve conduction studies, showed abnormalities with fibrillation potentials and the rapid recruitment of small polyphasic motor units in the examined muscles, as well as a reduced amplitude of the compound muscle action potential and sensory nerve action potential, with an absence of demyelinating features. Pre-transplant clinical status was critical in all patients. During ICU stay, early allograft dysfunction, acute kidney injury, prolonged mechanical ventilation, sepsis, hyperglycemia, and high blood transfusions were observed in all patients. Two patients were retransplanted. Five patients were alive at 90 days; two patients died. In non-cooperative OLT patients, neurophysiological investigations are essential for the diagnosis of ICU-AW. In this setting, the high number of red blood cell transfusions is a potential risk factor for ICU-AW.

Background: Hepatic dysfunction (HD) after liver transplantation (LT) or extended hepatic resection (EHR) is associated with graft failure and high short-term mortality. We evaluated the safety and depurative efficacy of CytoSorb® in these settings. The primary endpoint was the change in serum total bilirubin at the end of the treatment compared to the baseline value. The secondary endpoint was to evaluate the trend of serum total bilirubin and coagulation parameters up to 72 h after discontinuation of CytoSorb®. The effects of CytoSorb® therapy on the degree of hepatic encephalopathy (HE), Sequential Organ Failure Assessment (SOFA), and Model for End-Stage Liver Disease (MELD) scores as well as the hemodynamic status compared to baseline were also assessed. Methods: Adult patients with a serum total bilirubin level > 10 mg/dL admitted to the Intensive Care Unit were included. Exclusion criteria were hemodynamic instability, postoperative bleeding and platelet count < 20,000/mm3. Results: Seven patients were treated. Serum total bilirubin was significantly reduced at the end of treatment. However, seventy-two hours after the discontinuation of extracorporeal therapy, bilirubin levels returned to baseline levels in four patients. A decrease in platelet count was found during therapy, and platelet transfusion was required in six cases. A significant increase in D-dimer at the end of treatment was detected. HE degree, SOFA and MELD scores remained stable, while a deterioration in hemodynamic status was observed in two cases. Conclusions: Our preliminary findings did not show the possible benefits of CytoSorb^® in rebalancing clinical and laboratory parameters in patients with HD after LT or EHR.

Background: Thromboelastography-6s (TEG^®6s), a novel device developed to assess coagulation status, presents advantages such as less frequent calibration, ease of use, and greater stability against movements compared to the previous system (TEG5000). This is the first study in the literature to compare coagulation profiles in the early postoperative period of liver resection (LR) using conventional coagulation tests (CCTs) and TEG^®6s. Methods: Forty-six adult patients admitted to the ICU post-surgery after elective LR for malignancy were included. CCTs were used to classify patients into hypocoagulable (HCG) (platelet count < 80 × 10⁹/L, international normalized ratio ≥ 1.4, or activated partial thromboplastin time > 38 s) and normocoagulable (all other cases) groups. Mann–Whitney tests, Spearman’s correlation, and linear regression were used. Results: On ICU admission, nineteen (41.3%) patients had a hypocoagulable profile based on CCTs, but only two (10.5%) of them were rated as hypocoagulable by TEG (p = 0.165). Intraoperatively, HCG patients experienced higher estimated blood loss (EBL) (p = 0.002); they required more fluids (p = 0.019), and more of them received red blood cell transfusions (p = 0.025). They also had higher postoperative arterial lactate levels (p = 0.036). Postoperative 12 h EBL was similar in the two groups (around 150 mL). The ICU stay was longer for HCG group (p = 0.010). Weak associations were observed between TEG/CCTs measures of coagulation initiation [e.g., between R time citrated rapid TEG, and international normalized ratio (r² = 0.448; p < 0.001)], clot formation [i.e., between conventional fibrinogen value using Clauss method and α-angle citrated rapid TEG (r² = 0.542; p < 0.001)], and clot strength [e.g., between conventional fibrinogen and citrated kaolin maximum amplitude (r² = 0.484; p < 0.001)]. Conclusions: CCTs revealed hypocoagulability that was not confirmed by TEG^®6s. However, the thromboelastography coagulation profile was more consistent with the detected non-relevant postoperative bleeding.

Background: Acute kidney injury (AKI) is a frequent and severe complication after liver transplantation (LT), occurring in 30–60% of cases. It increases mortality, prolongs hospital stay, and increases the risk of chronic kidney disease. Intraoperative, modifiable anesthetic factors play a key preventive role. This systematic review synthesizes the overall prevalence of AKI and examines the evidence linking intraoperative anesthetic management to AKI after LT, emphasizing modifiable factors that may inform future perioperative strategies. Methods: We conducted a systematic, computerized search on PubMed, EMBASE, Cochrane Library, and Scopus from January 2004 to November 16, 2025, following a registered protocol on PROSPERO (ID: CRD420250580749). Randomized controlled trials (RCTs) and cohort studies assessing intraoperative predictors of AKI were considered eligible for inclusion. The primary outcome was the incidence of post-LT AKI. Intraoperative factors associated with post-LT AKI, including intraoperative hypotension, fluid therapy, transfusion strategies, and the use of vasopressors and/or inotropic agents, were also assessed. Results: A total of 50 studies (8 RCTs and 42 cohort studies) involving 22,434 patients were included. The pooled incidence of post-LT AKI from observational studies was 41% (95% CI 36–46%). Across the included studies, intraoperative hemodynamic instability, excessive or unbalanced fluid administration, liberal transfusion practices, and suboptimal use of vasopressors were consistently associated with an increased risk of post-transplant AKI. Conclusions: AKI after LT is mainly influenced by modifiable perioperative factors. Prevention relies on maintaining stable hemodynamics, careful fluid and transfusion management, and avoiding intraoperative hypotension. Prompt and adequate vasopressor support appeared protective. A multimodal, personalized, kidney-protective approach is essential for improving post-transplant outcomes.

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