The pulmonary artery catheter is invasive and may cause serious complications. A safe method of cardiac output (CO) measurement is needed. We have assessed the accuracy and reliability of a recently marketed self-calibrating arterial pulse contour CO monitoring system (FloTrac/Vigileo™) in end-stage liver failure patients undergoing liver transplant. The pattern of alterations known as cirrhotic cardiomyopathy, and the transplant procedure itself, provided an evaluation under varying clinical conditions. The cardiac index was measured simultaneously by thermodilution (CI_TD: mean of four readings) using a pulmonary artery catheter and pulse contour analysis (CI_V: mean value computed by the FloTrac/Vigileo™ over the same time period). Readings were made at 10 time-points during liver transplant surgery (T1–T5) and on the intensive care unit (T6–T10). CI_V was computed using the latest Vigileo software version 01.10. A total of 290 paired readings from 29 patients were collected. Mean (sd) CI_TD was 5.2 (1.3) and CI_V was 3.9 (0.9) litre min⁻¹ m⁻², with a corrected for repeated measures bias between readings of 1.3 (0.2) litre min⁻¹ m⁻² and 95% limits of agreement of −1.5 (0.2) to 4.1 (0.3) litre min⁻¹ m⁻². The percentage error (2sd_Bias/meanCI_TD) was 54%, which exceeded a 30% limit of acceptance. Low peripheral resistance and increasing bias were related (r=0.69; P<0.001). The Vigileo system failed to reliably trend CI data, with a concordance compared with thermodilution below an acceptable level (at best 68% of sequential readings). In cirrhotic patients with hyperdynamic circulation, the Vigileo system showed a degree of error and unreliability higher than that considered acceptable for clinical purposes.

Older donors are a growing part of the total donor pool but no definite consensus exists on the limit of age for their acceptance. From November 1998 to January 2003, in a retrospective case-control multicenter study, we compared the outcome of 30 orthotopic liver transplantations (OLTs) with octogenarian donors and of 60 chronologically correlated OLTs performed with donors <40 years. The percentage of refusal was greater among older than younger donors (48.2 vs. 14.3%; p < 0.001). Cold ischemia was significantly shorter in the older than younger groups. Recipients with hepatocarcinoma and older age received octogenarian grafts more frequently. No differences were seen in post-operative complications and 6-month graft and patient survival. However, long-term survival was lower in patients transplanted with octogenarian donors (p = 0.04). Interestingly, the mortality related to hepatitis C recurrence was greater in patients with octogenarian donors. Accordingly, the long-term survival of HCV-positive patients who received older grafts was lower than those receiving younger grafts (p = 0.05). Octogenarian livers can be used safely but a careful donor evaluation and a short cold ischemia are required to prevent additional risk factors. However, hepatitis C recurrence is associated with a greater mortality in patients who received octogenarian grafts raising concerns whether to allocate these livers to HCV-positive recipients.

Reducing postoperative mechanical ventilation in patients undergoing liver transplantation may have clinical and organizational advantages. On the basis of our experience, we here evaluate the possibility of practising immediate tracheal extubation in the operating theatre. In this prospective study, patients consecutively undergoing liver transplantation between 1 June 1999 and 31 May 2004 were extubated in the operating theatre at the end of surgery on the basis of standardized and universally accepted criteria, under conditions of haemodynamic and metabolic stability. Two hundred and seven of the 354 patients (58.5%) were extubated immediately after the completion of the surgical procedure (mean time between end of surgery and extubation: 0.4 +/- 1.4 min); two were re-intubated. In the last of the 5 yr of the study, the percentage of immediate extubations increased to 82.5%. During the study period, there was a progressive increase in the number of immediate extubations per individual member of the team of anaesthetists. The pre-transplant Child-Pugh severity of the underlying liver disease did not predict rapid extubation, but the Model for End-stage Liver Disease score of < 11 did (receiver operator characteristic area under the curve = 0.61; P < 0.05). Immediate extubation after liver transplantation is possible in a substantial percentage of cases; confidence, habit and a spirit of emulation are decisive factors in encouraging anaesthetists to extend this practice to the largest possible number of patients. A successful immediate extubation may be an important indicator of perioperative quality of care in liver transplantation.