Int J Clin Exp Med 2018;11(8):8196-8204 www.ijcem.com /ISSN:1940-5901/IJCEM0065538 Original Article Effects of sodium bicarbonate on hepatic injury after left lateral hepatectomy with inflow occlusion: a retrospective study Li Gong1, Chao Dong2, Yongzhong Tang1, Wen Ouyang1 1Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan, China; 2Xiangya International Medical Center-Surgical Ward, Department of Geriatrics, Xiangya Hospital, Central South University, Changsha 410008, Hunan, China Received September 13, 2017; Accepted April 2, 2018; Epub August 15, 2018; Published August 30, 2018 Abstract: Ischemia-reperfusion injury induced by blocking the portal triad is a common clinical pathophysiological event during the hepatic lobectomy. We retrospectively investigated whether perioperative administration of sodium bicarbonate decreases occurrence of postoperative hepatic injury. 158 patients diagnosed with intrahepatic stone received left lateral lobectomy with inflow occlusion from Jan 2011 to Mar 2017. Control (n=124) and the sodium bicarbonate (n=34) groups were assigned depending on whether they intraoperatively received sodium bicarbonate or not. The data of alanine aminotransferase (ALT), aspartate transaminase (AST) and total Bilirubin, reflecting liver functions, on the pre-operative day, the first day and the third day after operation were collected and compared. Patients of two groups were well balanced for baseline characteristics. The AST level significantly decreased in the sodium bicarbonate group on the first day after operation compared with Control group (p=0.0058). 150 ml of intra- venous sodium bicarbonate showed a significant attenuate in increased plasma AST, ALT and total Bilirubin levels at one day after operation compared with 50 and 100 ml (all p < 0.05), but not on the third day after operation (p > 0.05). Significant differences were found in BE, sodium, bicarbonate levels both one hour after occlusion and after surgery in the sodium bicarbonate group compared with Control group. And the number of patients treated with hepatic protective drugs on the second day after surgery declined significantly in the sodium bicarbonate group compared with Control group (p=0.0194). A particular volume of sodium bicarbonate can reduce hepatic injury after left lateral lobectomy of liver with inflow occlusion on the first day after operation and alleviate the burden of postoperative liver protective drugs usage. Keywords: Sodium bicarbonate, hepatic ischemia-reperfusion injury, left lateral lobectomy Introduction on, play critical roles in hepatic IR injury [6-8]. And a variety of promising protective approach- Temporary portal triad clamping is one com- es have been explored to reduce the injury. mon methodology of reducing bleeding and Ischemic preconditioning, surgical strategies transfusion during hepatic lobectomy since the and pharmacological therapies with different early 20th century [1, 2]. Unfortunately, isch- targets play a predominant role in minimizing emia/reperfusion (IR)-induced ischemic injury the hepatic IR injury in experimental animals in the remnant liver remains a frequent and and clinical [9, 10]. However, effective ways to major complication after portal triad clamping. prevent hepatic IR injury are not available so far It compromises liver function and increases [11]. postoperative morbidity, mortality, progress, recovery, and overall outcomes [3-5]. A great Sodium bicarbonate was used to attenuate number of in-depth studies focused on the free radical formation and inhibit oxidase st- complicated mechanism underlying hepatic IR ress [12]. It has high accessibility and is a low- injury. It is now becoming clear that oxidative cost, easy-to-use drug in clinical. It’s also sug- stress, inflammatory response, the impairment gested that sodium bicarbonate serves as a of mitochondria and vascular integrity and so possible strategy for prevention of nephropathy Sodium bicarbonate and hepatic injury Material and methods Patients The de-identified data was retrospectively obtained from Jan 2011 to Mar 2017 from the structured hospital infor- mation system (HIS) and An- esthesia system of our insti- tute, in accordance with local ethical committee approval. Figure 1. Protocol of surgical procedure and outcome measures. 364 ASA physical status I/II/ III adult patients, who were diagnosed as intrahepatic bile duct stone and under- went left lateral lobectomy of liver + cholecystectomy + T- tube drainage + common bile duct exploration with or with- out inflow occlusion. The ex- clusion criteria were (1) diabe- tes mellitus; (2) preoperative hepatic dysfunctions; (3) hem- angioma; (4) hepatic occupi- ed lesion; (5) hepatitis; (6) scheduled resection not re- quiring hepatic portal occlu- sion; (7) reoperation; (8) peri- operative transfusion; (9) ad- ministration of hepatic pro- tective drugs on the first day after operation; (10) blood loss in operation > 700 ml; (11) occlusion time > 30 min. And in the patients with in- flow occlusion during surgery, Figure 2. Study Flow and Distribution of participants through each stage of the control and sodium bicar- the retrospective study. bonate groups were assign- ed depending on whether they in patients undergoing coronary angiography preoperatively received sodium bicarbonate or patients with systemic inflammatory res- or not. And in the sodium bicarbonate group, ponse syndrome or sepsis and oliguria [13, 50 ml up to 150 ml of sodium bicarbonate was 14]. But it has been rarely reported about the intravenous once within 20 minutes before effect of sodium bicarbonate on hepatic IR occlusion during surgery (Figure 1). And the injury induced by the hepatolobectomy with volume of sodium bicarbonate infused periop- inflow occlusion. To address these issues, we eratively was depending on the anesthetists’ retrospectively collected data to check wheth- experiences and decision. er intraoperative administration of sodium bi- carbonate reduced hepatic injury in patients Anesthesia management undergoing left lateral lobectomy of liver with inflow occlusion, with hopes of developing a All the patients were under general anesthesia simple and effective therapy to diminish the with tracheal intubation. They were given mid- injury. azolam (0.1-0.15 mg/kg), propofol (1.5-2 mg/ 8197 Int J Clin Exp Med 2018;11(8):8196-8204 Sodium bicarbonate and hepatic injury kg), sulfentanil (0.5-0.8 μg/kg) and cisatra- tive variables, and Fisher’s exact tests were curium (0.15 mg/kg) for routine anesthesia used for categorical variables. Results were induction. Anesthesia was all maintained with assessed using one-way analysis of variance propofol, cisatracurium, remifentanil and sevo- (ANOVA) followed by Student’s t-test. Statistic- flurane. All the patients were treated with arte- al analysis was implemented with Prism 6 rial radialis puncture for direct manometric (GraphPad Software, Inc., CA, USA), during wh- method and arterial blood gas analysis. A cen- ich p values less than 0.05 were considered tral venous catheter was indwelled for monitor- statistically significant. ing the central venous pressure and infusing of fluids or transfusion. In addition, ECG, blood Results pressure, SpO2, EtCO2 and urine volume were checked continuously as a routine during sur- We conducted a single-center, retrospective gery. Arterial blood gas analysis in the patients study of hospitalized adults from Jan 2011 to with hepatic portal interdiction during surgery Mar 2017. In total, 592 patients who under- were carried out at least three times: preopera- went left lateral lobectomy of liver + cholecys- tively, immediately after surgery and 24 hours tectomy + T-tube drainage + common bile duct after surgery. Patients were extubated once exploration were considered potential candi- awake in PACU. dates. We identified 498 subjects in the struc- tured hospital information system (HIS) of our Study outcomes institute who were diagnosed with intrahepatic stone. 94 patients were excluded with a dis- Basic characteristics such as ASA, sex, and age charge diagnosis of ‘haemangioma’ or ‘hepatic were gathered and compared between the occupied lesion’ and so on. And another 134 groups. The operation time, blood loss, occlu- patients were next ruled out, as they had hepa- sion time, urine outputs, anesthesia manage- titis, reoperation, perioperative transfusion, ment and number of patients requiring vaso- blood loss > 700 ml, occlusion time > 30 min. pressin were also compared. The comparison Finally, 364 patients underwent the operations of anesthesia management included dosages with (B and C groups, n=158) or without hepat- of different anesthetic drugs including sufent- ic portal interdiction (A group, n=206) were anil, sevoflurane and so on. Postoperative con- assessed for eligibility. And 158 patients of ditions including the hospital stay time, inci- them enrolled were divided into the sodium dence of acute liver failure, pulmonary infection, bicarbonate group (C group, n=124) who re- number of patients who had postoperative con- ceived intravenous sodium bicarbonate intra- trolled intravenous analgesia (PCIA) and num- operatively, and Control group (B group, n=34) ber of patients received hepatic protective (Figure 2). A detailed description of baseline drugs on the second day after surgery were demographic characteristics of enrolled pa- also compared. tients is given in Table 1. No significant differ- ences were found between the groups (B vs. The primary