Kiểm soát áp lực tĩnh mạch trung tâm thấp nhằm giảm mất máu trong cắt gan: Tổng quan mô tả
Nội dung chính của bài viết
Tóm tắt
Kiểm soát mất máu trong phẫu thuật cắt gan có ảnh hưởng đến kết cục lâm sàng. Chiến lược duy trì áp lực tĩnh mạch trung tâm (CVP) thấp được áp dụng nhằm giảm chảy máu qua giảm áp lực thủy tĩnh tại xoang gan. Bài tổng quan hệ thống hóa các phương pháp hạ CVP để kiểm soát mất máu trong phẫu thuật cắt gan. Tổng quan mô tả qua tra cứu PubMed/MEDLINE đến tháng 2/2026. Từ khóa: CVP thấp, cắt gan, mất máu. Các biện pháp hạ CVP chia thành hai nhóm. Nhóm thiếu dịch tuyệt đối (hạn chế dịch, lợi niệu, trích máu giảm thể tích) đạt CVP đích nhanh, giảm mất máu hiệu quả nhưng có thể kéo dài thời gian nằm viện. Nhóm tái phân bố dịch bằng thuốc giãn mạch đạt tỷ lệ thành công 85 - 92%; Milrinone có vẻ ưu thế hơn Nitroglycerin nhờ tác dụng kép giãn mạch- trợ tim. Điều chỉnh thông khí giảm CVP tốt nhưng cần tránh gây ưu thán làm giãn mạch gan.
Chi tiết bài viết
Từ khóa
Cắt gan, áp lực tĩnh mạch trung tâm thấp, thuốc giãn mạch, mất máu chu phẫu
Tài liệu tham khảo
1. Jarnagin WR, Gonen M, Fong Y, et al. Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg. 2002; 236(4): 397-406; discussion 406-407. doi:10.1097/01.SLA.0000029003.66466.B3.
2. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev. 2007; 21(6): 327-348. doi:10.1016/j.blre.2007.07.003.
3. Simillis C, Li T, Vaughan J, Becker LA, Davidson BR, Gurusamy KS. Methods to decrease blood loss during liver resection: a network meta-analysis. Cochrane Database Syst Rev. 2014; (4): CD010683. doi:10.1002/14651858.CD010683.pub2.
4. Karanicolas PJ, Lin Y, McCluskey SA, et al. Tranexamic Acid in Patients Undergoing Liver Resection: The HeLiX Randomized Clinical Trial. JAMA. 2024; 332(13): 1080-1089. doi:10.1001/jama.2024.11783.
5. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg. 1998; 85(8): 1058-1060. doi:10.1046/j.1365-2168.1998.00795.x.
6. Melendez JA, Arslan V, Fischer ME, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg. 1998; 187(6): 620-625. doi:10.1016/s1072-7515(98)00240-3.
7. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
8. Lin CX, Guo Y, Lau WY, et al. Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int HBPD INT. 2013; 12(5): 520-524. doi:10.1016/s1499-3872(13)60082-x.
9. Pan YX, Wang JC, Lu XY, et al. Intention to control low central venous pressure reduced blood loss during laparoscopic hepatectomy: A double-blind randomized clinical trial. Surgery. 2020;167(6):933-941. doi:10.1016/j.surg.2020.02.004
10. Erkoç SK, Kırımker EO, Büyük S, et al. Reducing Risk for Acute Kidney Injury After Living Donor Hepatectomy by Protocolized Fluid Restriction: Single-Center Experience. Transplant Proc. 2022; 54(8): 2243-2247. doi:10.1016/j.transproceed.2022.08.006.
11. Téoule P, Dunker N, Debatin J, et al. Reduction of Central Venous Pressure in Elective Robotic and Laparoscopic Liver Resection: The PRESSURE Trial-A Randomized Clinical Study. Ann Surg. 2025; 282(2): 210-218. doi:10.1097/SLA.0000000000006721.
12. Lapisatepun W, Chotirosniramit A, Junrungsee S, et al. Impact of Hypovolemic Phlebotomy With Low Central Venous Pressure on Intraoperative Blood Loss in Open Liver Resection: A Double-Blind Randomized Controlled Trial. Ann Surg. 2026; 283(2): 203-211. doi:10.1097/SLA.0000000000006760.
13. Zatloukal J, Pradl R, Kletecka J, Skalicky T, Liska V, Benes J. Comparison of absolute fluid restriction versus relative volume redistribution strategy in low central venous pressure anesthesia in liver resection surgery: a randomized controlled trial. Minerva Anestesiol. 2017; 83(10): 1051-1060. doi:10.23736/S0375-9393.17.11824-9.
14. Jongerius IM, Mungroop TH, Uz Z, et al. Goal-directed fluid therapy vs. low central venous pressure during major open liver resections (GALILEO): a surgeon- and patient-blinded randomized controlled trial. HPB. 2021; 23(10): 1578-1585. doi:10.1016/j.hpb.2021.03.013.
15. Téoule P, Dunker N, Debatin J, et al. Reduction of Central Venous Pressure in Elective Robotic and Laparoscopic Liver Resection: The PRESSURE Trial-A Randomized Clinical Study. Ann Surg. 2025; 282(2): 210-218. doi:10.1097/SLA.0000000000006721.
16. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol WJG. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
17. Yang P, Gao S, Chen X, Xiong W, Hai B, Huang X. Milrinone is better choice for controlled low central venous pressure during hepatectomy: A randomized, controlled trial comparing with nitroglycerin. Int J Surg. 2021; 94:106080. doi:10.1016/j.ijsu.2021.106080.
18. Lv H, Jiang X, Huang X, et al. Nitroglycerin versus milrinone for low central venous pressure in patients undergoing laparoscopic hepatectomy: a double-blinded randomized controlled trial. BMC Anesthesiol. 2024; 24(1): 244. doi:10.1186/s12871-024-02631-5.
19. Vincenzi P, et al. Nitroglycerin infusion for controlled low central venous pressure in laparoscopic liver resection: a dose-finding and safety study. Surgeries. 2019; 14(2): 112-120 - Google Search. Accessed May 29, 2026.
20. Hasegawa K, Takayama T, Orii R, et al. Effect of hypoventilation on bleeding during hepatic resection: a randomized controlled trial. Arch Surg. 2002; 137(3): 311-315. doi:10.1001/archsurg.137.3.311.
21. Iguchi T, Ikegami T, Fujiyoshi T, Yoshizumi T, Shirabe K, Maehara Y. Low Positive Airway Pressure without Positive End-Expiratory Pressure Decreases Blood Loss during Hepatectomy in Living Liver Donors. Dig Surg. 2017; 34(3): 192-196. doi:10.1159/000447755.
22. Redondo FJ, Padilla D, Villazala R, Villaeiro P, Baladron V, Bejerano N. Global end-diastolic volume could be more appropiate to reduce intraoperative bleeding than central venous pressure during major liver transection. Anestezjol Intensywna Ter. 2017; 49(2): 100-105. doi:10.5603/AIT.2017.0030.
23. Ratti F, Cipriani F, Reineke R, et al. Intraoperative monitoring of stroke volume variation versus central venous pressure in laparoscopic liver surgery: a randomized prospective comparative trial. HPB. 2016; 18(2): 136-144. doi:10.1016/j.hpb.2015.09.005.
24. Choi SS, Jun IG, Cho SS, Kim SK, Hwang GS, Kim YK. Effect of stroke volume variation-directed fluid management on blood loss during living-donor right hepatectomy: a randomised controlled study. Anaesthesia. 2015; 70(11): 1250-1258. doi:10.1111/anae.13155.
25. Chirnoaga D, Coeckelenbergh S, Ickx B, et al. Impact of conventional vs. goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver surgery: A pilot randomised controlled trial. Eur J Anaesthesiol. 2022; 39(4): 324-332. doi:10.1097/EJA.0000000000001615.
26. Coeckelenbergh S, Soucy-Proulx M, Van der Linden P, et al. Restrictive versus Decision Support Guided Fluid Therapy during Major Hepatic Resection Surgery: A Randomized Controlled Trial. Anesthesiology. 2024; 141(5): 881-890. doi:10.1097/ALN.0000000000005175.
2. Vamvakas EC, Blajchman MA. Transfusion-related immunomodulation (TRIM): an update. Blood Rev. 2007; 21(6): 327-348. doi:10.1016/j.blre.2007.07.003.
3. Simillis C, Li T, Vaughan J, Becker LA, Davidson BR, Gurusamy KS. Methods to decrease blood loss during liver resection: a network meta-analysis. Cochrane Database Syst Rev. 2014; (4): CD010683. doi:10.1002/14651858.CD010683.pub2.
4. Karanicolas PJ, Lin Y, McCluskey SA, et al. Tranexamic Acid in Patients Undergoing Liver Resection: The HeLiX Randomized Clinical Trial. JAMA. 2024; 332(13): 1080-1089. doi:10.1001/jama.2024.11783.
5. Jones RM, Moulton CE, Hardy KJ. Central venous pressure and its effect on blood loss during liver resection. Br J Surg. 1998; 85(8): 1058-1060. doi:10.1046/j.1365-2168.1998.00795.x.
6. Melendez JA, Arslan V, Fischer ME, et al. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg. 1998; 187(6): 620-625. doi:10.1016/s1072-7515(98)00240-3.
7. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
8. Lin CX, Guo Y, Lau WY, et al. Optimal central venous pressure during partial hepatectomy for hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int HBPD INT. 2013; 12(5): 520-524. doi:10.1016/s1499-3872(13)60082-x.
9. Pan YX, Wang JC, Lu XY, et al. Intention to control low central venous pressure reduced blood loss during laparoscopic hepatectomy: A double-blind randomized clinical trial. Surgery. 2020;167(6):933-941. doi:10.1016/j.surg.2020.02.004
10. Erkoç SK, Kırımker EO, Büyük S, et al. Reducing Risk for Acute Kidney Injury After Living Donor Hepatectomy by Protocolized Fluid Restriction: Single-Center Experience. Transplant Proc. 2022; 54(8): 2243-2247. doi:10.1016/j.transproceed.2022.08.006.
11. Téoule P, Dunker N, Debatin J, et al. Reduction of Central Venous Pressure in Elective Robotic and Laparoscopic Liver Resection: The PRESSURE Trial-A Randomized Clinical Study. Ann Surg. 2025; 282(2): 210-218. doi:10.1097/SLA.0000000000006721.
12. Lapisatepun W, Chotirosniramit A, Junrungsee S, et al. Impact of Hypovolemic Phlebotomy With Low Central Venous Pressure on Intraoperative Blood Loss in Open Liver Resection: A Double-Blind Randomized Controlled Trial. Ann Surg. 2026; 283(2): 203-211. doi:10.1097/SLA.0000000000006760.
13. Zatloukal J, Pradl R, Kletecka J, Skalicky T, Liska V, Benes J. Comparison of absolute fluid restriction versus relative volume redistribution strategy in low central venous pressure anesthesia in liver resection surgery: a randomized controlled trial. Minerva Anestesiol. 2017; 83(10): 1051-1060. doi:10.23736/S0375-9393.17.11824-9.
14. Jongerius IM, Mungroop TH, Uz Z, et al. Goal-directed fluid therapy vs. low central venous pressure during major open liver resections (GALILEO): a surgeon- and patient-blinded randomized controlled trial. HPB. 2021; 23(10): 1578-1585. doi:10.1016/j.hpb.2021.03.013.
15. Téoule P, Dunker N, Debatin J, et al. Reduction of Central Venous Pressure in Elective Robotic and Laparoscopic Liver Resection: The PRESSURE Trial-A Randomized Clinical Study. Ann Surg. 2025; 282(2): 210-218. doi:10.1097/SLA.0000000000006721.
16. Wang WD, Liang LJ, Huang XQ, Yin XY. Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol WJG. 2006; 12(6): 935-939. doi:10.3748/wjg.v12.i6.935.
17. Yang P, Gao S, Chen X, Xiong W, Hai B, Huang X. Milrinone is better choice for controlled low central venous pressure during hepatectomy: A randomized, controlled trial comparing with nitroglycerin. Int J Surg. 2021; 94:106080. doi:10.1016/j.ijsu.2021.106080.
18. Lv H, Jiang X, Huang X, et al. Nitroglycerin versus milrinone for low central venous pressure in patients undergoing laparoscopic hepatectomy: a double-blinded randomized controlled trial. BMC Anesthesiol. 2024; 24(1): 244. doi:10.1186/s12871-024-02631-5.
19. Vincenzi P, et al. Nitroglycerin infusion for controlled low central venous pressure in laparoscopic liver resection: a dose-finding and safety study. Surgeries. 2019; 14(2): 112-120 - Google Search. Accessed May 29, 2026.
20. Hasegawa K, Takayama T, Orii R, et al. Effect of hypoventilation on bleeding during hepatic resection: a randomized controlled trial. Arch Surg. 2002; 137(3): 311-315. doi:10.1001/archsurg.137.3.311.
21. Iguchi T, Ikegami T, Fujiyoshi T, Yoshizumi T, Shirabe K, Maehara Y. Low Positive Airway Pressure without Positive End-Expiratory Pressure Decreases Blood Loss during Hepatectomy in Living Liver Donors. Dig Surg. 2017; 34(3): 192-196. doi:10.1159/000447755.
22. Redondo FJ, Padilla D, Villazala R, Villaeiro P, Baladron V, Bejerano N. Global end-diastolic volume could be more appropiate to reduce intraoperative bleeding than central venous pressure during major liver transection. Anestezjol Intensywna Ter. 2017; 49(2): 100-105. doi:10.5603/AIT.2017.0030.
23. Ratti F, Cipriani F, Reineke R, et al. Intraoperative monitoring of stroke volume variation versus central venous pressure in laparoscopic liver surgery: a randomized prospective comparative trial. HPB. 2016; 18(2): 136-144. doi:10.1016/j.hpb.2015.09.005.
24. Choi SS, Jun IG, Cho SS, Kim SK, Hwang GS, Kim YK. Effect of stroke volume variation-directed fluid management on blood loss during living-donor right hepatectomy: a randomised controlled study. Anaesthesia. 2015; 70(11): 1250-1258. doi:10.1111/anae.13155.
25. Chirnoaga D, Coeckelenbergh S, Ickx B, et al. Impact of conventional vs. goal-directed fluid therapy on urethral tissue perfusion in patients undergoing liver surgery: A pilot randomised controlled trial. Eur J Anaesthesiol. 2022; 39(4): 324-332. doi:10.1097/EJA.0000000000001615.
26. Coeckelenbergh S, Soucy-Proulx M, Van der Linden P, et al. Restrictive versus Decision Support Guided Fluid Therapy during Major Hepatic Resection Surgery: A Randomized Controlled Trial. Anesthesiology. 2024; 141(5): 881-890. doi:10.1097/ALN.0000000000005175.