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Diaphragm Muscle Surface Electromyography in Patients Submitted to Liver Transplant and Eligible for Extubation
Diaphragm Muscle Surface Electromyography in Patients Submitted to Liver Transplant and Eligible for Extubation R.P. Duarte, A.C. Sentanin, A.M.O. da Silva, R.M. Tonella, G.L. Duarte, L.S.R. Ratti, and I.F.S.F. Boin* Unit of Liver Transplantation, Faculty of Medical Sciences, State University of Campinas, Campinas, Brazil
ABSTRACT Introduction. Liver disease induces many organic and metabolic changes, leading to malnutrition and weight and muscular function loss. Surface electromyography is an easily applicable, noninvasive study, through which the magnitudes of the peaks on the charts depict voluntary muscle activity. Aim. To evaluate the diaphragmatic surface electromyography of postoperative liver transplantation subjects. Methods. Subjects were patients who underwent liver transplantation and extubation in the Clinical Hospital of State University of Campinas. Electromyography data were collected with support pressure of 10 cm H2O, Glasgow Coma Scale ¼ 11, and minimum dosages of vasoactive drugs, and data were collected again 30 minutes after extubation. Signal collection was performed with sEMG System Brazil SAS1000V3 electromyograph and electrode stickers. Statistical analysis was performed using R software. Results. The average time of surgery was 345.36 125.62 minutes. Time from spontaneous mode until extubation was 417.14 362.97 minutes. The RMS (root mean square) values of the right and left domes in spontaneous mode with minimal ventilation parameters were 26.68 10.92 and 26.55 10.53, respectively, and the RMS values after extubation were 31.93 18.69 to 34.62 13.55, for right and left domes. The last calculated pretransplant Model for End-stage Liver Disease score averaged 19.64 8.41. Conclusion. There were significant differences between the RMS of the diaphragm domes under mechanical ventilation and after extubation, showing lower effectiveness of the diaphragm muscle against resistance, without the aid of positive pressure and the existing overload of the left dome.
L
IVER disease induces many organic and metabolic changes, leading to malnutrition and weight and muscular function loss [1]. The main cause of liver disease is cirrhosis, mostly related to alcohol, cholestatic disorders, and viral infections [2]. There are many treatments, and among them, hepatic transplantation stands out [3]. The Model for End-stage Liver Disease (MELD) radically changed the organization of the transplant waiting list, which currently does not follow a chronological order, but an order according to the risk of death [2]. Surface electromyography is an easily applicable, noninvasive study, through which the magnitudes of the peaks on the charts depict voluntary muscle activity. The
ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 49, 829e831 (2017)
RMS (root mean square) value, obtained through the amplitude of the electromyographic signal [4], provides important electrodiagnostic information, collaborating with the research [5]. The aim of this study was to evaluate the electromyography of the diaphragmatic surface on postoperative liver transplantation subjects, to measure the RMS values at 2 different times: when patients were under invasive mechanical ventilation and after extubation (Fig 1). *Address correspondence to Ilka Fatima Santana Ferreira Boin, Rua Aldo Oliveira Barbosa 184, Campinas, SP, Brazil CEP 13086-030. E-mail: [email protected] 0041-1345/17 http://dx.doi.org/10.1016/j.transproceed.2017.01.059
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DUARTE, SENTANIN, DA SILVA ET AL
Fig 1. (A) Root of mean square (RMS) comparison of the right dome under spontaneous mode with minimal ventilation parameter and after extubation, showing a statistically significant difference (P ¼ .0295). (B) RMS comparison of left dome under spontaneous mode with minimal ventilation parameter and after extubation, showing a statistically significant difference (P ¼ .0166).
METHODS Clinical and prospective study included patients of both sexes, 18 to 70 years old, who underwent liver transplantation. These subjects were informed, agreed to participate in the study, and signed the Free Informed Consent form. All of the subjects had their immediate postoperative period in the Liver Transplantation Intensive Care Unit at the Clinical Hospital of State University of Campinas, were still under mechanical ventilation, and became eligible for extubation with hemodynamic and respiratory stability. Information about the history of the patients and the surgical procedure were collected from medical records. Surface electromyography was performed when patients became eligible for extubation, and the research team did not interfere at any time in the eligibility decision. Electromyography was performed in 2 stages: in spontaneous mode on mechanical ventilator with minimal ventilation parameters of pressure support ventilation ¼ 10 cm H2O, positive endexpiratory pressure ¼ 8 cm H2O, and inspired oxygen fractions, 40%, and again after performing extubation (up to 30 minutes). Collection of electromyographic signals occurred in supine position in 35 of head-of-bed elevation, using the surface electromyograph sEMG System Brazil Ltda 0547-15 Series, Model SAS1000V3, and adhesive electrodes (3M, SP, Brazil). Two electrodes were placed in the paraxiphoid region, 5 cm below the xiphoid process, and the other 2, in the bilateral costal margin region with a distance of about 16 cm between them [5].
Table 1. Mean, Standard Deviation, Minimum and Maximum Values of the Variables Studied Mean
SD
Min
Max
Age (y) 57.42 7.09 44.00 69.00 MELD 19.64 8.41 10.00 41.00 Surgical time (min) 345.36 125.52 180.00 600.00 Extubation time (min) 417.14 362.97 60.00 1425.00 RMS right dome SP (mV) 26.68 10.92 11.66 51.25 RMS left dome SP (mV) 26.55 10.53 10.62 42.73 RMS right dome after extubation 31.93 18.69 11.39 82.14 (mV) RMS left dome after extubation (mV) 34.62 13.55 12.39 61.65 Abbreviations: MELD, Model for End-stage Liver Disease; Max, maximum; Min, minimum; RMS, root of mean square; SD, standard deviation; SP, support pressure.
Signal acquisition was performed at a frequency of 500 Hz and a signal range sensitivity of 500 mV. Data were read in a Samsung Ultrabook computer. Statistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria) and encompassed Wilcoxon test to compare related variables and Pearson correlation for descriptive analysis between 2 metric scale variables. P values <.05 were considered statistically significant.
RESULTS
The sample consisted of 14 patients who underwent liver transplantation and were eligible for extubation. The average age was 52.47 7.09 years; 71.42% were male patients (n ¼ 10) and 28.58% were female patients (n ¼ 4). The reasons for transplantation were primarily hepatocellular carcinoma (n ¼ 5), cirrhosis caused by fulminant hepatitis, hemochromatosis and cryptogenic cirrhosis (n ¼ 4), hepatitis B or C (n ¼ 3), and alcohol (n ¼ 2). The average time of surgery was 345.36 125.62 minutes. The time from the opening of the spontaneous mode until extubation was 417.14 362.97 minutes. The RMS values of the right and left domes in spontaneous mode with minimal ventilation parameters were 26.68 10.92 and 26.55 10.53, respectively. The RMS values after extubation were 31.93 18.69 to 34.62 13.55 for the right and left domes. The last calculated pretransplant MELD score averaged 19.64 8.41 (Table 1). Statistically significant values were obtained when relating pre- and postextubation RMS for the right and left domes and before and after extubation. Overall, Pearson correlations were considered moderate to strong.
DISCUSSION
The sex of individuals who underwent transplantation does not present any impact on the survival of the same. However, male subjects present higher incidences of transplantation when compared with female subjects (2:1) [6,7], which corroborates with the profile of the patients from the present study, in which more than 70% were men.
DIAPHRAGM MUSCLE SURFACE ELECTROMYOGRAPHY
Another variable studied was the time of use of the mechanical ventilation, from the opening of spontaneous mode until extubation, which was an average of 417.14 362.97 minutes. The standard deviation was very large due to the heterogeneity of the sample and the response of each individual organism to the anesthetic medication dose used during the procedure. In this context, Rocco and Soares [7] conducted a study with patients who underwent different types of surgery, in which 147 underwent liver transplantation and presented the highest prevalence of mechanical ventilation in the postoperative period. These data are not in agreement with this study, because the vast majority of patients were extubated in the immediate postoperative period (n ¼ 9, 64.3%), as in the study by Sentanin et al [8]. Therefore, the previously existing muscle weakness in these patients did not interfere in the outcome of extubation, even after transplantation. The RMS values of liver disease patients in da Silva et al [4] (56.56 34.64) were higher than the RMS of healthy subjects (49.39 17.88), which can be justified by the metabolic and mechanical changes that liver disease patients may handle. However, the values obtained in this study were 31.93 18.69 and 34.62 13.55 for the right and left domes, respectively, and show a much smaller value in comparison to the previously mentioned study. This may be justified by the fact that the majority of the transplant patients in this study remained for a short time on the waiting list due to their hepatocellular carcinoma diagnosis, which allows them to be placed in a special situation at the transplant waiting list. Another factor evidenced in this study is that the RMS of the left dome proved to be worse than the right dome, in both extubated and still under mechanical ventilation modes. This may be incited by an overload of the left dome as a result of the malfunctioning of the right dome caused by the damaged liver. Another influencing aspect is the need for diaphragmatic denervation by surgical technique for better handling. The RMS values of the domes under mechanical ventilation and after extubation were significantly different. The RMS of the right and left domes under mechanical ventilation with positive pressure showed a better value when compared with postextubation RMS (P ¼ .0295 and P ¼ .0166, respectively). This goes against the findings of Sentanin et al [8], which showed a worse function of the right dome and justified it by the handling of this side during
831
the transplant procedure and distension after procedure that further compromise pulmonary function. A limiting factor of this study is the small sample size and the difficulty of collecting electromyographic data due to lack of intensive care unit (ICU) staff training, because liver transplantation subjects usually enter the ICU in the early morning and there is no possibility of collection due to lack of trained personnel. Also, other variables related to muscle strength were not evaluated, as well as the evolution of the patients discharged from the ICU, and therefore further studies in the subject are needed. CONCLUSION
In conclusion, the RMS values of the domes under mechanical ventilation and after extubation were significantly different, indicating a lower effectiveness of the diaphragm muscle against resistance, without the aid of positive pressure and the existing overload of the left dome. There were not enough data to conclude that the MELD and the time of surgery can interfere in postsurgical outcome of liver transplant patients. REFERENCES [1] Galant LH, Forgiarini Junior LA, Dias AS, Marroni CA. Functional status, respiratory muscle strength, and quality of life in patients with cirrhosis. Rev Bras Fisioter, Sao Carlos 2012;16:30e4. [2] David AI, Paula M, Coelho V, Paes ÂT, Leite AK, Della Guardia B, et al. Liver transplant outcome: a comparison between high and low MELD score recipients. Einstein 2012;10:57e61. [3] Noujaim HM, de Ville de Goyet J, Montero EF, Ribeiro CMF, Capellozzi VF, Crescentini F, et al. Expanding postmortem donor pool using steatitic liver grafts: A new look. Transplantation 2009;87(6):919e25. [4] da Silva ÁMO, Cliquet Jr A, Boin Ide FSF. Profile of respiratory evaluation through surface electromyography, manovacuometry, and espirometry in candidates on the liver transplant waiting list. Transplant Proc 2012;44:2403e5. [5] Oliveira Da Silva AM, Maturi S, Boin IFSF. Comparison of surface electromyography in respiratory muscles of healthy and liver disease patients: preliminary studies. Transplant Proc 2011;43:1325e6. [6] Thuluvath PJ, Guidinger MK, Fung JJ, Johnson LB, Rayhill SC, Pelletier SJ. Liver transplantation in the United States, 1999-2008. Am J Transplant 2010;10:1003e19. [7] Rocco JR, Soares M. Outcome of patients with cirrhosis admitted to intensive care. Rev Bras Ter Intensiva 2010;22:11e8. [8] Sentanin AC, Duarte RP, da Silva AMO, Ratti L dos SR, Tonella RM, Boin Ide FSF. Surface electromyography of the diaphragm muscle in patients submitted to liver transplantationd preliminary data. J Bras Transplantes 2014;17:16e20.
ABSTRACT Introduction. Liver disease induces many organic and metabolic changes, leading to malnutrition and weight and muscular function loss. Surface electromyography is an easily applicable, noninvasive study, through which the magnitudes of the peaks on the charts depict voluntary muscle activity. Aim. To evaluate the diaphragmatic surface electromyography of postoperative liver transplantation subjects. Methods. Subjects were patients who underwent liver transplantation and extubation in the Clinical Hospital of State University of Campinas. Electromyography data were collected with support pressure of 10 cm H2O, Glasgow Coma Scale ¼ 11, and minimum dosages of vasoactive drugs, and data were collected again 30 minutes after extubation. Signal collection was performed with sEMG System Brazil SAS1000V3 electromyograph and electrode stickers. Statistical analysis was performed using R software. Results. The average time of surgery was 345.36 125.62 minutes. Time from spontaneous mode until extubation was 417.14 362.97 minutes. The RMS (root mean square) values of the right and left domes in spontaneous mode with minimal ventilation parameters were 26.68 10.92 and 26.55 10.53, respectively, and the RMS values after extubation were 31.93 18.69 to 34.62 13.55, for right and left domes. The last calculated pretransplant Model for End-stage Liver Disease score averaged 19.64 8.41. Conclusion. There were significant differences between the RMS of the diaphragm domes under mechanical ventilation and after extubation, showing lower effectiveness of the diaphragm muscle against resistance, without the aid of positive pressure and the existing overload of the left dome.
L
IVER disease induces many organic and metabolic changes, leading to malnutrition and weight and muscular function loss [1]. The main cause of liver disease is cirrhosis, mostly related to alcohol, cholestatic disorders, and viral infections [2]. There are many treatments, and among them, hepatic transplantation stands out [3]. The Model for End-stage Liver Disease (MELD) radically changed the organization of the transplant waiting list, which currently does not follow a chronological order, but an order according to the risk of death [2]. Surface electromyography is an easily applicable, noninvasive study, through which the magnitudes of the peaks on the charts depict voluntary muscle activity. The
ª 2017 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 49, 829e831 (2017)
RMS (root mean square) value, obtained through the amplitude of the electromyographic signal [4], provides important electrodiagnostic information, collaborating with the research [5]. The aim of this study was to evaluate the electromyography of the diaphragmatic surface on postoperative liver transplantation subjects, to measure the RMS values at 2 different times: when patients were under invasive mechanical ventilation and after extubation (Fig 1). *Address correspondence to Ilka Fatima Santana Ferreira Boin, Rua Aldo Oliveira Barbosa 184, Campinas, SP, Brazil CEP 13086-030. E-mail: [email protected] 0041-1345/17 http://dx.doi.org/10.1016/j.transproceed.2017.01.059
829
830
DUARTE, SENTANIN, DA SILVA ET AL
Fig 1. (A) Root of mean square (RMS) comparison of the right dome under spontaneous mode with minimal ventilation parameter and after extubation, showing a statistically significant difference (P ¼ .0295). (B) RMS comparison of left dome under spontaneous mode with minimal ventilation parameter and after extubation, showing a statistically significant difference (P ¼ .0166).
METHODS Clinical and prospective study included patients of both sexes, 18 to 70 years old, who underwent liver transplantation. These subjects were informed, agreed to participate in the study, and signed the Free Informed Consent form. All of the subjects had their immediate postoperative period in the Liver Transplantation Intensive Care Unit at the Clinical Hospital of State University of Campinas, were still under mechanical ventilation, and became eligible for extubation with hemodynamic and respiratory stability. Information about the history of the patients and the surgical procedure were collected from medical records. Surface electromyography was performed when patients became eligible for extubation, and the research team did not interfere at any time in the eligibility decision. Electromyography was performed in 2 stages: in spontaneous mode on mechanical ventilator with minimal ventilation parameters of pressure support ventilation ¼ 10 cm H2O, positive endexpiratory pressure ¼ 8 cm H2O, and inspired oxygen fractions, 40%, and again after performing extubation (up to 30 minutes). Collection of electromyographic signals occurred in supine position in 35 of head-of-bed elevation, using the surface electromyograph sEMG System Brazil Ltda 0547-15 Series, Model SAS1000V3, and adhesive electrodes (3M, SP, Brazil). Two electrodes were placed in the paraxiphoid region, 5 cm below the xiphoid process, and the other 2, in the bilateral costal margin region with a distance of about 16 cm between them [5].
Table 1. Mean, Standard Deviation, Minimum and Maximum Values of the Variables Studied Mean
SD
Min
Max
Age (y) 57.42 7.09 44.00 69.00 MELD 19.64 8.41 10.00 41.00 Surgical time (min) 345.36 125.52 180.00 600.00 Extubation time (min) 417.14 362.97 60.00 1425.00 RMS right dome SP (mV) 26.68 10.92 11.66 51.25 RMS left dome SP (mV) 26.55 10.53 10.62 42.73 RMS right dome after extubation 31.93 18.69 11.39 82.14 (mV) RMS left dome after extubation (mV) 34.62 13.55 12.39 61.65 Abbreviations: MELD, Model for End-stage Liver Disease; Max, maximum; Min, minimum; RMS, root of mean square; SD, standard deviation; SP, support pressure.
Signal acquisition was performed at a frequency of 500 Hz and a signal range sensitivity of 500 mV. Data were read in a Samsung Ultrabook computer. Statistical analyses were performed using R software (R Foundation for Statistical Computing, Vienna, Austria) and encompassed Wilcoxon test to compare related variables and Pearson correlation for descriptive analysis between 2 metric scale variables. P values <.05 were considered statistically significant.
RESULTS
The sample consisted of 14 patients who underwent liver transplantation and were eligible for extubation. The average age was 52.47 7.09 years; 71.42% were male patients (n ¼ 10) and 28.58% were female patients (n ¼ 4). The reasons for transplantation were primarily hepatocellular carcinoma (n ¼ 5), cirrhosis caused by fulminant hepatitis, hemochromatosis and cryptogenic cirrhosis (n ¼ 4), hepatitis B or C (n ¼ 3), and alcohol (n ¼ 2). The average time of surgery was 345.36 125.62 minutes. The time from the opening of the spontaneous mode until extubation was 417.14 362.97 minutes. The RMS values of the right and left domes in spontaneous mode with minimal ventilation parameters were 26.68 10.92 and 26.55 10.53, respectively. The RMS values after extubation were 31.93 18.69 to 34.62 13.55 for the right and left domes. The last calculated pretransplant MELD score averaged 19.64 8.41 (Table 1). Statistically significant values were obtained when relating pre- and postextubation RMS for the right and left domes and before and after extubation. Overall, Pearson correlations were considered moderate to strong.
DISCUSSION
The sex of individuals who underwent transplantation does not present any impact on the survival of the same. However, male subjects present higher incidences of transplantation when compared with female subjects (2:1) [6,7], which corroborates with the profile of the patients from the present study, in which more than 70% were men.
DIAPHRAGM MUSCLE SURFACE ELECTROMYOGRAPHY
Another variable studied was the time of use of the mechanical ventilation, from the opening of spontaneous mode until extubation, which was an average of 417.14 362.97 minutes. The standard deviation was very large due to the heterogeneity of the sample and the response of each individual organism to the anesthetic medication dose used during the procedure. In this context, Rocco and Soares [7] conducted a study with patients who underwent different types of surgery, in which 147 underwent liver transplantation and presented the highest prevalence of mechanical ventilation in the postoperative period. These data are not in agreement with this study, because the vast majority of patients were extubated in the immediate postoperative period (n ¼ 9, 64.3%), as in the study by Sentanin et al [8]. Therefore, the previously existing muscle weakness in these patients did not interfere in the outcome of extubation, even after transplantation. The RMS values of liver disease patients in da Silva et al [4] (56.56 34.64) were higher than the RMS of healthy subjects (49.39 17.88), which can be justified by the metabolic and mechanical changes that liver disease patients may handle. However, the values obtained in this study were 31.93 18.69 and 34.62 13.55 for the right and left domes, respectively, and show a much smaller value in comparison to the previously mentioned study. This may be justified by the fact that the majority of the transplant patients in this study remained for a short time on the waiting list due to their hepatocellular carcinoma diagnosis, which allows them to be placed in a special situation at the transplant waiting list. Another factor evidenced in this study is that the RMS of the left dome proved to be worse than the right dome, in both extubated and still under mechanical ventilation modes. This may be incited by an overload of the left dome as a result of the malfunctioning of the right dome caused by the damaged liver. Another influencing aspect is the need for diaphragmatic denervation by surgical technique for better handling. The RMS values of the domes under mechanical ventilation and after extubation were significantly different. The RMS of the right and left domes under mechanical ventilation with positive pressure showed a better value when compared with postextubation RMS (P ¼ .0295 and P ¼ .0166, respectively). This goes against the findings of Sentanin et al [8], which showed a worse function of the right dome and justified it by the handling of this side during
831
the transplant procedure and distension after procedure that further compromise pulmonary function. A limiting factor of this study is the small sample size and the difficulty of collecting electromyographic data due to lack of intensive care unit (ICU) staff training, because liver transplantation subjects usually enter the ICU in the early morning and there is no possibility of collection due to lack of trained personnel. Also, other variables related to muscle strength were not evaluated, as well as the evolution of the patients discharged from the ICU, and therefore further studies in the subject are needed. CONCLUSION
In conclusion, the RMS values of the domes under mechanical ventilation and after extubation were significantly different, indicating a lower effectiveness of the diaphragm muscle against resistance, without the aid of positive pressure and the existing overload of the left dome. There were not enough data to conclude that the MELD and the time of surgery can interfere in postsurgical outcome of liver transplant patients. REFERENCES [1] Galant LH, Forgiarini Junior LA, Dias AS, Marroni CA. Functional status, respiratory muscle strength, and quality of life in patients with cirrhosis. Rev Bras Fisioter, Sao Carlos 2012;16:30e4. [2] David AI, Paula M, Coelho V, Paes ÂT, Leite AK, Della Guardia B, et al. Liver transplant outcome: a comparison between high and low MELD score recipients. Einstein 2012;10:57e61. [3] Noujaim HM, de Ville de Goyet J, Montero EF, Ribeiro CMF, Capellozzi VF, Crescentini F, et al. Expanding postmortem donor pool using steatitic liver grafts: A new look. Transplantation 2009;87(6):919e25. [4] da Silva ÁMO, Cliquet Jr A, Boin Ide FSF. Profile of respiratory evaluation through surface electromyography, manovacuometry, and espirometry in candidates on the liver transplant waiting list. Transplant Proc 2012;44:2403e5. [5] Oliveira Da Silva AM, Maturi S, Boin IFSF. Comparison of surface electromyography in respiratory muscles of healthy and liver disease patients: preliminary studies. Transplant Proc 2011;43:1325e6. [6] Thuluvath PJ, Guidinger MK, Fung JJ, Johnson LB, Rayhill SC, Pelletier SJ. Liver transplantation in the United States, 1999-2008. Am J Transplant 2010;10:1003e19. [7] Rocco JR, Soares M. Outcome of patients with cirrhosis admitted to intensive care. Rev Bras Ter Intensiva 2010;22:11e8. [8] Sentanin AC, Duarte RP, da Silva AMO, Ratti L dos SR, Tonella RM, Boin Ide FSF. Surface electromyography of the diaphragm muscle in patients submitted to liver transplantationd preliminary data. J Bras Transplantes 2014;17:16e20.