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Vasodilation due to impaired vascular tone is common in liver failure. Vasoconstrictor drugs are almost always required during the anhepatic phase of a liver transplant to maintain blood pressure unless venovenous bypass is employed. Arginine-vasopressin can be used as a vasoconstrictor instead of or in addition to norepinephrine for this purpose, but the effect of vasopressin on the portal vein pressure and flow in this setting is unknown. Portal vein pressure, portal vein blood flow, hemodynamic variables, and plasma vasopressin levels were measured in 16 patients during liver transplantation after ligation of the hepatic artery before and after a vasopressin infusion of 3.8 +/- 1.1 units/hour. Measurements were performed on the native liver prior to caval clamping. After vasopressin infusion, the portal vein pressure decreased significantly from 24.0 +/- 6.5 to 21.5 +/- 7.4 mm Hg [mean +/- standard deviation (SD), P = 0.006]. The portal vein blood flow also decreased (from 1.01 +/- 0.53 to 0.76 +/- 0.53 L/minute, mean +/- SD, P < 0.0001), as did the portal vein blood flow to cardiac output ratio (from 0.14 +/- 0.06 to 0.10 +/- 0.07, mean +/- SD, P < 0.0001). In conclusion, vasopressin significantly decreased portal vein pressure and flow of the native liver without decreasing cardiac output or intestinal perfusion in patients undergoing liver transplantations.

This article demonstrates the broad range of considerations that affect the outcome of patients undergoing hepatectomy. The progressive improvements in survival, despite the increasing complexity of the surgery, area testament to advances in both surgery and anesthesia. The key elements include careful patient selection, appropriate monitoring, and mechanical and pharmacologic protection of the liver and other vital organs.

Point of care testing (POCT), a new paradigm in laboratory testing, has recently been introduced to the critical care setting. In this model, laboratory testing is performed in the critical care vicinity by local bedside personnel. POCT devices perform user selected critical care tests on whole blood in a timely and accurate fashion. The POCT data, while used immediately at the bedside, must still be managed in accordance with regulatory guidelines and incorporated into the laboratory or hospital information system. Currently, critical care physicians are not educated and trained in the intricacies of laboratory data management and device interfacing. This article addresses the technical, political, and implementation issues surrounding POCT data management and interfacing as well as the philosophical and practical differences in laboratory data management between the central laboratory and POCT sites.