Clinical relevance of time of onset, duration, and type of pulmonary edema after liver transplantation

Abstract

We investigated the clinical significance of time of onset, duration, and type of pulmonary edema after orthotopic liver transplantation by retrospectively reviewing 93 consecutive recipients. Pulmonary edema was diagnosed by means of radiographic criteria and PaO 2 /FIO 2 ratio <300. Type was identified by pulmonary artery wedge pressure (hydrostatic, >18 mm Hg; permeability, <18 mm Hg O rthotopic liver transplantation is an accepted treatment for patients with end-stage liver disease. Survival after transplantation has been improving steadily, with a current one-year survival rate of 86.9% for patients and 81.3% for grafts. 1 Nonetheless, early pulmonary complications are common and known to contribute significantly to morbidity and mortality. 2 The most frequent pulmonary complications are pleural effusion, atelectasis, pulmonary edema, and pneumonia. [3][4][5] Pulmonary edema occurs in 14% to 47% of liver transplant recipients. [6][7][8][9][10] It is diagnosed clinically by the combination of bilateral radiographic infiltrates and impaired oxygenation. 11 The purpose of this study was to investigate the clinical significance of the time of onset and the duration of pulmonary edema after orthotopic liver transplantation in consecutive liver transplant recipients. In addition, we investigated whether the traditional classification of pulmonary edema 12 into hydrostatic or permeability types is associated with different outcomes. Methods Patients and Transplantation ProceduresThe medical records of all consecutive patients who underwent orthotopic liver transplantation at Mayo Clinic, Jacksonville, Florida, from February 25, 1998, to October 1, 1999, were retrospectively reviewed. This series represents the first 93 consecutive liver transplant recipients in our transplantation program.All liver transplantation procedures were performed using the piggyback technique without venovenous bypass. Pulmonary arterial catheters were inserted intraoperatively to facilitate hemodynamic management. Patients routinely received small amounts of epinephrine boluses at the time of graft reperfusion but had no sustained need for vasoconstrictor or inotropic support. Decisions regarding administration of fluids and blood products were made according to standards for care to provide hemodynamic stability and correction of unexpected coagulation abnormalities and bleeding. All patients were admitted to the intensive care unit (ICU) immediately after surgery and then extubated as soon as they met standard criteria for termination of mechanical ventilation, such as presence of adequate gas exchange function, hemodynamic stability, and ability to protect the airway. Pulmonary EdemaRadiographic, arterial oxygenation, and hemodynamic data were collected to evaluate patients for pulmonary edema preoperatively on the day of surgery and postoperatively on admission to the ICU and 16 to 24 hours after the operation. A chest radiologist and two pulmonary intensivists evaluated

Respiratory risk score for the prediction of 3-month mortality and prolonged ventilation after liver transplantation

“…A PaO 2 /FiO 2 ratio less than 200 mm Hg indicates severe deterioration of lung function early after transplantation and is frequently due to pulmonary edema. A similar finding was published before …”

Meeting report of the 19th Annual International Congress of the International Liver Transplantation Society (Sydney Convention and Exhibition Centre, Sydney, Australia, June 12‐15, 2013)

“…Posttransplant ALI was associated with prolonged mechanical ventilation, an increased hospital stay, and graft failure. These data demonstrated a decreasing incidence of ALI and improved survival in comparison with earlier reports …”

Extravascular Lung Water and Pulmonary Vascular Permeability Index Measured at the End of Surgery Are Independent Predictors of Prolonged Mechanical Ventilation in Patients Undergoing Liver Transplantation

“…Such values are an ominous sign in the immediate postoperative OLT period. Aduen et al 29 found that patients with PEs on chest radiography and PCPs <18 mm Hg have worse outcomes than those with PEs that are accompanied by PCPs >18 mm Hg (29% vs 0% mortality, respectively). Snowden et al 5 also noted that the presence of pulmonary infiltrate is suggestive of PE in patients undergoing OLT not only because of hydrostatic causes.…”