Pulse pressure variation–guided versus low central venous pressure–guided fluid management during elective open hepatectomy: a randomized non-inferiority trial

Abstract

Background

Low central venous pressure (LCVP)–guided fluid management is widely used to reduce blood loss during liver resection; however, LCVP is an unreliable marker of preload. Pulse pressure variation (PPV) is a dynamic index of fluid responsiveness. This study evaluated whether a PPV-guided fluid management strategy is non-inferior to conventional LCVP-guided management in reducing intraoperative blood loss during elective open hepatectomy.

Methods

In this single-center, randomized, non-inferiority trial, adult patients (18–65 years) with American Society of Anesthesiologists physical status I–II scheduled for elective, non-donor open hepatic resection involving two or more segments were randomized to either an LCVP-guided group or a PPV-guided group. Fluid administration in both groups followed predefined hemodynamic algorithms. The primary outcome was intraoperative blood loss. Secondary outcomes included total intraoperative fluid administration, urine output, serum lactate concentrations, and postoperative renal function. Non-inferiority was assessed using a prespecified margin of 98 ml.

Results

Sixty-four patients (32 in each group) were included in the final analysis. Intraoperative blood loss was comparable between the LCVP and PPV groups (683 ± 276 ml vs. 726 ± 223 ml, respectively). The mean difference in blood loss was − 43 ml (95% confidence interval: −169 to 83 ml), with the upper limit remaining below the predefined non-inferiority margin, confirming non-inferiority of the PPV-guided strategy. Total crystalloid and colloid administration, urine output, surgical field grading, and perioperative serum lactate levels were similar between the two groups. Postoperative serum creatinine levels at 24 h did not differ significantly.

Conclusions

PPV-guided fluid management was non-inferior to an LCVP-based strategy for reducing intraoperative blood loss during elective open hepatic resection, without evidence of compromised tissue perfusion. These findings suggest that PPV-guided fluid management may be a feasible alternative to CVP-targeted fluid management in this setting.

Trial registration

The trial was registered prospectively with the Clinical Trials Registry of India (CTRI/2018/01/011547; registered on 24 January 2018).

Introduction

Liver resection is frequently associated with significant intraoperative blood loss, which adversely affects perioperative outcomes and long-term survival [1–3]. Excessive blood loss and perioperative fluid overload are independent predictors of postoperative morbidity, prolonged hospital stay, and impaired recovery following hepatectomy. Consequently, optimization of intraoperative hemodynamic and fluid management remains a cornerstone of anesthetic care during hepatic resections.

Several techniques—including low central venous pressure (LCVP), hypoventilation, portal triad clamping, and topical hemostatic agents—have been used to minimize bleeding during hepatectomy [4–7]. Among these, LCVP has traditionally been considered the standard strategy, as reducing right atrial pressure enhances venous drainage from hepatic veins and sinusoids, thereby decreasing blood loss during parenchymal transection. Despite its widespread use, central venous pressure is a static, indirect measure of preload and is influenced by factors such as patient positioning, positive end-expiratory pressure, cardiac function, and surgical manipulation [4, 6]. These limitations may lead to an inaccurate assessment of intravascular volume status and inappropriate fluid administration. As a result, there has been increasing interest in dynamic indices of fluid responsiveness that better reflect heart–lung interactions during mechanical ventilation.

Dynamic parameters such as stroke volume variation (SVV) and pulse pressure variation (PPV) have demonstrated superior predictive accuracy for fluid responsiveness compared with static preload indices [8–10]. SVV-guided fluid management during LCVP-assisted hepatectomy has been shown to optimize fluid balance and reduce volume overload [11]. Similarly, PPV is a reliable predictor of volume responsiveness and performs better than CVP [12]. Despite its routine use in operating rooms and critical care settings, the role of PPV-guided fluid therapy in reducing intraoperative blood loss during major hepatectomy remains insufficiently investigated.

We therefore hypothesized that a PPV-guided fluid management strategy would be non-inferior to an LCVP-guided approach in reducing intraoperative blood loss during elective open hepatectomy. The primary objective of this randomized controlled trial was to compare intraoperative blood loss between PPV-guided and LCVP-guided fluid management strategies. Secondary objectives included comparison of intraoperative fluid administration, surgical field quality, markers of tissue perfusion, and early postoperative renal function.

Materials and methods

Study design

This prospective, randomised, controlled, single-center non-inferiority trial was conducted between February 2018 and June 2020 at a tertiary care academic hospital in North India. Ethical approval for this study (Reference No: NK/3334/MD/2741-42) was provided by the Institutional Ethics Committee of Post graduate institute of medical education & research, Chandigarh, India (Chairperson Prof. Nandita Kakkar). This trial was performed according to the Declaration of Helsinki, and registered prospectively with the Clinical Trials Registry of India (CTRI/2018/01/011547; registered on 24 January 2018). Written informed consent was obtained from all participants. This study was designed and reported in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement for randomized controlled trials.

Inclusion and exclusion criteria

Adult patients aged ≥ 18 years with American Society of Anesthesiologists (ASA) physical status I–II scheduled for elective, non-donor open hepatic resection involving two or more liver segments were eligible for inclusion. Exclusion criteria included combined resections involving other organs, ASA physical status ≥ III, body mass index ≥ 35 kg/m², heart failure, significant arrhythmias (including atrial fibrillation or flutter), cirrhosis with ascites, pregnancy, severe pulmonary disease, and inability to provide informed consent.

Randomization and group allocation

Participants were randomized in a 1:1 ratio to either the low central venous pressure (LCVP) group or the pulse pressure variation (PPV) group using a computer-generated randomization sequence. Allocation concealment was achieved using sequentially numbered, opaque, sealed envelopes, which were opened only after patient enrollment. In both groups, intraoperative fluid management was conducted according to predefined, protocolized hemodynamic algorithms.

Blinding

Participants, the operative surgeon, and outcome assessors were blinded to group allocation. The attending anaesthesiologist administering intraoperative fluid therapy was not blinded due to the nature of the intervention. Intraoperative blood loss and postoperative outcomes were assessed by blinded investigators, while surgical field grading was performed by the blinded operating surgeon. Both groups received identical anaesthetic, surgical, and perioperative care except for the intraoperative haemodynamic management strategy.

Anaesthetic monitoring and management

Patients were continuously monitored in the operating room using multichannel monitors (Datex-Ohmeda S/5 Avance, GE Healthcare), including electrocardiography (ECG), heart rate (HR), non-invasive and invasive blood pressure (BP), oxygen saturation (SpO₂), and end-tidal carbon dioxide (EtCO₂). Anaesthesia was induced with intravenous fentanyl (2 µg/kg), propofol (2–3 mg/kg) followed by atracurium (0.5 mg/kg) to facilitate endotracheal intubation. Anesthesia was maintained with isoflurane (MAC 1–1.3) in a 50% air–oxygen mixture under positive pressure ventilation, targeting an EtCO₂ of 32–36 mmHg. A thoracic epidural catheter was placed at the T6–T8 level in all patients for analgesia.

Mechanical ventilation was provided in volume-controlled mode using a tidal volume of 8 ml/kg of predicted body weight, with respiratory rate adjusted to maintain end-tidal carbon dioxide between 32 and 36 mmHg and a positive end-expiratory pressure of 5 cmH₂O. Neuromuscular blockade was maintained throughout the procedure to prevent spontaneous breathing efforts, thereby ensuring the reliability of dynamic preload indices. A central venous catheter was placed via the right internal jugular vein for central venous pressure monitoring and administration of fluids and vasoactive agents. Invasive arterial pressure monitoring and pulse pressure variation measurement were obtained through a radial arterial catheter connected to a calibrated pressure transducer system.

All patients underwent central venous catheterization via the right internal jugular vein for CVP monitoring and administration of fluids or vasopressors. Invasive arterial pressure and PPV were monitored via a radial artery catheter inserted in the non-dominant hand.

Hemodynamic targets and vasoactive support

Mean arterial pressure was maintained at ≥ 65 mmHg throughout surgery. Transient hypotension was treated with intravenous phenylephrine boluses (1.5 µg/kg). A continuous norepinephrine infusion was initiated in cases of persistent hypotension (mean arterial pressure ≤ 65 mmHg) despite bolus therapy.

Fluid management protocols

All patients received a balanced salt solution (BSS) beginning with a 150-ml bolus at induction, followed by a maintenance infusion of 2 ml/kg/h. Subsequent fluid administration differed according to group allocation and followed predefined algorithms. (Fig. 1) In both the PPV and LCVP groups, adjunct measures to decrease preload when CVP exceeded 5 mmHg or PPV decreased below 13%, and to optimize the surgical field during the pre-transection and transection phases, included a 15° reverse Trendelenburg position, epidural bolus administration (0.25% bupivacaine, 3 mL), and selective intravenous furosemide (5–10 mg bolus), administered at the discretion of the attending anaesthesiologist when additional preload reduction was required.

Fig. 1.

Hemodynamic-guided fluid management algorithms. LCVP, Low central venous pressure; PPV, Pulse pressure variation; BSS, Balanced Salt solution; * assessment of augmented PPV as described by Min et al. [13]

LCVP group

The target was to maintain a CVP of < 5 mm Hg during the pre-transection and transection phases until completion of hepatectomy. Measures used to reduce CVP included restricted intravenous fluid administration, epidural anaesthesia, a 15° reverse Trendelenburg position, and the use of diuretics. After hepatectomy, BSS were administered at a rate of 6–8 ml/kg/hour to maintain the CVP within the range of 8–12 mm Hg. An additional BSS bolus of 250 ml was administered if the CVP fell below 8 mm Hg.

PPV group

During the pre-transection and transection phases, efforts were made to maintain PPV above 13%. When PPV was > 13%, the existing fluid strategy was continued. If PPV decreased to < 13%, balanced salt solution (BSS) infusion was stopped, and additional preload-reducing measures were instituted, including a 15° reverse Trendelenburg position, epidural bolus administration, and consideration of diuretic therapy.

Following hepatectomy, BSS infusion was increased to 6–8 mL·kg⁻¹·h⁻¹. A 250-mL BSS bolus was administered when PPV exceeded 13%. BSS infusion was discontinued when PPV was < 9%. In patients where PPV was in “grey zone” (9–13%), the decision to administer fluids versus vasopressors was guided by an augmented PPV manoeuvre [13]. Tidal volume (VT) was temporarily increased from 8 to 12 mL·kg⁻¹, with a commensurate reduction in respiratory rate to maintain constant minute ventilation for two minutes. During the second minute of high-VT ventilation, PPV was reassessed. If PPV increased to > 17%, a 250-mL fluid bolus was administered; if PPV remained < 17%, the patient was managed with phenylephrine bolus.

Data recording

Total blood loss during surgery was calculated by subtracting the volume of irrigation saline used from the volume collected in the suction drain, and adding the volume of blood in soaked sponges and gauzes (determined by the weight difference between dry and blood-soaked sponges and gauzes). The surgical team estimated blood loss in the surgical field. Sponge and gauze weighing was performed in a standardized manner by the same blinded outcome assessor using the institutional protocol throughout the study. The same blinded surgical team performed all procedures, and blood loss estimation methods were applied consistently across both groups. Significant blood loss, leading to hemodynamic instability and/or a haemoglobin level below 7 g/dL on arterial blood gas analysis, was managed with blood transfusions.

Arterial blood gas analysis, including serum lactate concentration, was performed at three predefined time points: after induction of anaesthesia (baseline), following completion of hepatic resection, and at the end of surgery. Total volumes of crystalloids and colloids administered intraoperatively, and urine output were recorded.

The quality of the surgical field was assessed intraoperatively by the operating surgeon using a four-point grading scale. Grades were defined as follows: Grade I—very lax inferior vena cava (IVC) and hepatic veins with minimal bleeding at the resection plane, making surgery very easy; Grade II—lax IVC and hepatic veins with mild bleeding at the resection plane, making surgery easy; Grade III—tense IVC and hepatic veins with appreciable bleeding at the resection plane, making surgery somewhat difficult; and Grade IV—very tense IVC and hepatic veins with profuse bleeding at the resection plane, making surgery very difficult to perform [14]. Surgery duration and intraoperative hemodynamic variables, including heart rate and mean arterial pressure, were recorded at predefined intervals.

Postoperative renal function was assessed by measuring serum creatinine concentrations preoperatively and at 24 h after surgery. All perioperative data were prospectively recorded by an investigator not involved in intraoperative clinical management. At the end of the surgery, muscle relaxation was reversed, patients were extubated, and epidural pain management was continued for 48 h postoperatively.

Statistical analysis

The sample size was calculated based on data from a previous study reporting a mean intraoperative blood loss of 490 ± 115 ml in patients undergoing LCVP-assisted hepatectomy [14]. A non-inferiority margin of 20% (98 ml) was prespecified. A difference of less than 100 ml in intraoperative blood loss during major hepatectomy is unlikely to alter the threshold for intraoperative blood transfusion (typically triggered by haemoglobin < 7 g/dL or haemodynamic compromise), to change the quality of the transection field, or to influence surgical decision-making regarding the need for additional haemostatic measures. This threshold is consistent with margins used in prior studies evaluating haemostatic and haemodynamic interventions in hepatic surgery.

Using a one-sided significance level (α) of 0.025, a total sample size of 56 patients was required to achieve 90% power to demonstrate non-inferiority. To account for an anticipated attrition rate of approximately 10%, 64 patients were enrolled. The primary analysis was performed on a per-protocol population, as recommended for non-inferiority trials. Patients who were randomized but subsequently found to have inoperable disease were excluded from the final analysis. Non-inferiority of the PPV-guided strategy was concluded if the upper bound of the two-sided 95% confidence interval for the between-group difference in blood loss did not exceed the prespecified non-inferiority margin.

Data distribution was assessed for normality using the Kolmogorov–Smirnov test. Continuous variables with normal distribution are presented as mean ± standard deviation and were compared between groups using Student’s unpaired t-test. Non-normally distributed continuous variables are presented as median (interquartile range) and were compared using the Mann–Whitney U test. Categorical variables are expressed as numbers (percentages) and were compared using the Chi-square test or Fisher’s exact test, as appropriate. Repeated measurements over time were analysed using repeated-measures analysis of variance.

The primary outcome of intraoperative blood loss was analysed according to the non-inferiority framework using a one-sided significance level of 0.025. Non-inferiority of the PPV-guided strategy was concluded if the upper bound of the two-sided 95% confidence interval for the between-group difference in blood loss did not exceed the prespecified non-inferiority margin of 98 ml. All secondary outcomes were analysed using two-sided tests, with a P value < 0.05 considered statistically significant.

Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) software, version 22 (IBM Corp., Armonk, NY, USA).

Results

Of the 84 patients assessed for eligibility, 71 were randomized to the LCVP group (n = 35) or PPV group (n = 36), while 13 patients were excluded prior to randomization due to predefined exclusion criteria or refusal to participate. After randomization, seven patients were excluded because of intraoperative findings of inoperable tumor (LCVP: n = 3; PPV: n = 4). Consequently, 32 patients in each group were included in the final analysis (Fig. 2).

Fig. 2.

Consort flow diagram. PPV, Pulse pressure variation; LCVP, Low central venous pressure; DCMP, Dilated cardiomyopathy; TR, Tricuspid regurgitation

Baseline demographic characteristics, preoperative haemoglobin concentration, body mass index, American Society of Anaesthesiologists physical status, and operative diagnoses were comparable between the two groups (Table 1).

Table 1.

Demographics and operative characteristics of patients undergoing liver resections

Demographics	LCVP group (n = 32)	PPV group (n = 32)	P Value
Age (years)	49.37 ± 13.28	53.43 ± 13.32	0.22a
BMI (kg.m− 2)	21.02 ± 2.99	21.23 ± 4.08	0.83a
Hb (mg.dL− 1)	11.71 ± 1.04	11.75 ± 1.71	0.91a
Sex
Male	10 (31%)	14 (44%)	0.44b
Female	22 (69%)	18 (56%)
ASA PS
I	24 (75%)	19 (59%)	0.40b
II	8 (25%)	13 (41%)	0.34b
Diagnosis
HCC	11 (34.3%)	12 (37.5%)
Cholangio-carcinoma	8 (25%)	11 (34.35)
Hepatic adenoma	6 (18.7%)	3 (9.3%)
Carcinoma Gall Bladder	4 (12.5%)	5 (15.6%)
Haemangioma	3 (9.3%)	1 (3.1%)

Values are presented as mean ± Standard deviation (SD), median (interquartile range [IQR]), or number (%), as appropriate. Hb Haemoglobin, BMI Body mass index, ASA-PS American Society of Anesthesiologists Physical Status classification, HCC

^aStudent’s t test

^bFisher’s exact test

Intraoperative blood loss, the primary outcome, did not differ significantly between the LCVP and PPV groups (683 ± 276 ml vs. 726 ± 223 ml, respectively). The mean difference in blood loss was − 43 ml (95% confidence interval − 169 to 83 ml; P = 0.39). The upper bound of the 95% confidence interval remained below the predefined non-inferiority margin of 98 ml, confirming non-inferiority of the PPV-guided fluid management strategy.

Among the secondary outcomes, total crystalloid and colloid administration showed no statistically significant differences between the two groups. Figure 3 illustrates box plots depicting intraoperative blood loss (Fig. 3A) and total crystalloid administration (Fig. 3B).

Fig. 3.

Boxplots showing blood loss & total crystalloid administered. Boxplot showing blood loss 4 (A) and total crystalloid administered 4 (B); LCVP, Low central venous pressure; PPV, Pulse pressure variation. Values on the Y-axis are expressed in ml

Surgical field grading was also similar between groups, with most patients demonstrating Grade I or II operative fields. Serum lactate levels measured at baseline, post-resection, and at the end of surgery, as well as postoperative serum creatinine levels at 24 h, showed no statistically significant differences between the LCVP and PPV groups (Table 2). However, the study was not powered to detect differences in these secondary outcomes.

Table 2.

Perioperative variables in patients with LCVP and PPV groups

Parameters	LCVP group (n = 32)	PPV group (n = 32)	Difference in means (95% CI)	P value
Blood loss (mL)	683 ± 276	726 ± 223	− 43 (-169 to 83)	0.39a
Total crystalloids (mL)	1726.87 ± 726.60	1574.37 ± 567.97	152(-173.77 to 478.77)	0.35a
Colloids (mL)	520 ± 179	292 ± 163	228 ( -4.53 to 461)	0.054a
PRBCs	13 (40%)	14 (43%)		0.29b
Duration of surgery (in minutes)	263.28 ± 118.38	257.50 ± 96.37		0.83a
Grading of surgical field
Grade I	23 (71.8%)	22 (68.7%)		0.80c
Grade II	7 (22.0%)	8 (25.0%)
Grade III	2 (6.2%)	2 (6.3%)
Grade IV	0	0
Vitals
HR-baseline (beats.min− 1)	74 ± 19	76 ± 20	-2 (-11.60 to 7.91)	0.70a
HR-end of resection (beats.min− 1)	95 ± 19	96 ± 22	-1 (-11.60 to 9.04)	0.80a
HR-end of surgery (beats.min− 1)	89 ± 16	95 ±19	-6 (-14.39 to 3.20)	0.21a
MAP-baseline (mmHg)	82 ± 12	80 ± 10	2 (-5.91 to 5.10)	0.88a
MAP-end of resection (mmHg)	72 ± 8	74 ± 13	-2 (-7.61 to 2.93)	0.37a
MAP-end of surgery (mmHg)	69 ± 11	72 ±12	-3 (-8.02 to 3.90)	0.49a
Urine output (mL)	250 ± 83.8	273 ± 67.5	19 (-27.7 to 48.3)	0.54a
Vasopressor/Inotropes
Noradrenaline infusion	17 (53.1%)	18 (56.3%)	-	1.00b
Phenylephrine Bolus	26 (81.3%)	28 (87.5%)	-	0.49b
Any vasoactive agent	31 (96.9%)	30 (93.8%)	-	1.00b
Investigations
Creatinine-baseline(mg.dL− 1)	0.70 ± 0.18	0.79 ± 0.26	-0.09 (-0.21 to 0.01)	0.09a
Creatinine-24 h (mg.dL− 1)	0.70 ± 0.16	0.81 ± 0.35	− 0.11 (-0.24 to 0.030)	0.12a
Albumin-baseline (mg.dL− 1)	3.85 ± 0.53	3.58 ± 0.57	0.27 (-0.003 to 0.54)	0.052a
Albumin-24 h (mg.dL− 1)	3.01 ± 0.33	2.89 ± 0.37	0.12 (-0.06 to 0.29)	0.19a
Lactate - post induction (mmol.L− 1)	1.25 ± 0.39	1.15 ± 0.34	0.09 (-0.07 to 0.28)	0.27a
Lactate - post resection (mmol.L− 1)	2.63 ± 1.48	2.24 ± 1.40	0.39 (-0.328 to 1.115)	0.28a
Lactate - end of surgery (mmol.L− 1)	2.53 ± 2.11	1.52 ± 0.371	1.01 (-0.121 to 2.15)	0.08a

Values are presented as mean ± Standard deviation (SD), median (interquartile range [IQR]), or number (%), as appropriate. HR Heart rate, MAP Mean Arterial pressure, PRBC\ Packed Red Blood cells. ^aStudent’s t test, ^bFisher’s exact test, ^cMann–Whitney U test

Discussion

In this randomized non-inferiority trial, we demonstrated that a pulse pressure variation–guided fluid management strategy is non-inferior to a conventional low central venous pressure–guided approach in reducing intraoperative blood loss during elective open hepatectomy. Fluid management throughout all stages of surgery was based on CVP and PPV values. A restrictive method was used before and during resection, aiming for CVP below 5 mm Hg and PPV above 13%. After resection, a more liberal strategy was adopted, with higher CVP targets between 8 and 12 mm Hg and PPV kept below 9%.

Previous studies reported that an LCVP technique can be extremely beneficial in reducing intraoperative blood loss and lowering the operative risk associated with hepatectomy [15–17]. A reduction in CVP lowers pressure in the inferior vena cava, hepatic veins, and sinusoids, thereby reducing blood loss during hepatectomy. Although the superiority of CVP has been established, it is prone to significant measurement errors. Factors like patient positioning, positive end expiratory pressure (PEEP), pulmonary disease, tricuspid valve disease and surgical factors (such as diaphragm retractors, liver mobilization, hepatic vessel clamping) can cause inaccurate CVP readings, suggesting the avoidance of central venous catheter (CVC) placement only for CVP monitoring [18, 19].

It is well established that dynamic indicators are superior to static ones in mechanically ventilated patients [20]. Pulse contour analysis systems automatically calculate dynamic indices of fluid responsiveness, such as PPV and SVV, which predict fluid responsiveness based on heart-lung interactions during mechanical ventilation [20]. Recently, high SVV has been used as an alternative to LCVP to reduce blood loss during parenchymal liver transection [21, 22]. Mizuonya et al. in their study used high SVV between 13 and 18% during the transection phase only and reported the beneficial effect of GDT protocol in reducing blood loss, but their before-after study design did not directly compare LCVP-assisted and SVV-guided GDT groups [11]. Dunki-Jacobs et al. reported that an SVV of 13% corresponded to a CVP of 3 mmHg during a hepatectomy, while Lee et al. reported that an SVV of 9%, comparable to a CVP of 5 mmHg, allowed a favourable resection plane as judged by surgeons [8, 22].

PPV, like SVV is another dynamic index, and the suitability of PPV in the operating room has been demonstrated in a meta-analysis [23]. The PPV has a high predictive accuracy to identify fluid responders, but values may be inconclusive between 9% and 13% (grey zone) in 25% of patients [12, 24]. Fluid management in this grey zone is ambiguous, with nearly 50% of patients potentially being fluid non-responders. We implemented the augmented PPV method validated by Min et al. to differentiate fluid responders from non-responders in this grey zone [13].

The volume of intravenous fluid administered intraoperatively was comparable in both groups in our study. In a previous study comparing goal-directed therapy (GDT) and standard therapy during the resection phase of hepatectomies, the GDT group received less fluid (mean difference of 900 ml) than the central venous pressure (CVP) group, but the incidence of postoperative complications was similar in both groups [25]. In our study, the PPV based fluid strategy had no significant effect on postoperative renal function, intraoperative crystalloid & colloid administration and perfusion parameters, assessed by serial measurements of serum lactate levels.

Our study has several limitations. Although adequately powered to establish non-inferiority for the primary outcome of intraoperative blood loss, it was not powered to assess non-inferiority for secondary outcomes including renal function, serum lactate, transfusion requirements, or surgical field quality. In addition, surgical expertise and institutional practices may influence outcomes, potentially limiting generalizability to other centers. The relatively small sample size and heterogeneity in surgical pathology may also have affected blood loss, transection time, and fluid requirements. Also, the findings may not be directly applicable to older or frailer patients, higher-risk ASA III populations, cirrhotic patients with ascites, laparoscopic resections, donor hepatectomy, or centers using different vasoactive, epidural, or fluid restriction protocols.

Conclusion

The results of this study suggested that a PPV-guided fluid management may be a feasible alternative to CVP-targeted fluid management during elective open hepatic resection. Further randomised studies are required to confirm the efficacy of GDT during hepatectomies on long-term outcomes.

Abbreviations

ASA

American Society of Anesthesiologists

BSS

Balanced Salt Solution

DBP

Diastolic Blood Pressure

HR

Heart Rate

LCVP

Low Central Venous Pressure

MAP

Positive End Expiratory Pressure

PPV

Pulse Pressure Variation

SBP

Systolic Blood Pressure

SPO₂

Blood Oxygen Saturation

SVV

Stroke Volume Variation

Authors’ contributions

ASA, KK, and VA conceived and designed the study. VA and KK were involved in patient recruitment, data collection, and intraoperative anesthetic management. AJH and SLS contributed to perioperative patient management and data acquisition. LK provided surgical coordination and clinical input. ASA performed the statistical analysis and drafted the manuscript. VA, KK, AJH, SLS, LK, and SS critically revised the manuscript for important intellectual content. All authors read and approved the final manuscript.

Funding

None.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Authors report that the content has not been published or submitted for publication elsewhere.

Ethics approval and consent to participate

Ethical approval for this study (Reference No: NK/3334/MD/2741-42) was provided by the Institutional Ethics Committee of Post graduate institute of medical education & research, Chandigarh, India (Chairperson Prof. Nandita Kakkar). Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.