Early perioperative death associated with reexpansion pulmonary edema during liver transplantation

Abstract

Hydrothorax is a frequent finding in patients with endstage liver disease. During the hepatectomy phase of liver transplantation, it is often needed to evacuate large pleural effusions. The acute expansion of the collapsed lung can cause reexpansion pulmonary edema with variable clinical significance. However, this complication has rarely been reported after liver transplantation. In conclusion, we report on an overwhelming reexpansion pulmonary edema during a liver transplantation that rapidly led to the patient's demise and speculate if this condition has not been under recognized in the transplantation setting. N oncardiogenic acute pulmonary edema (PE) may complicate the perioperative course of patients undergoing liver transplantation (LT). 1,2 Using radiography and partial pressure of oxygen, arterial/fraction of inspired oxygen ratio Ͻ300 as diagnostic criteria, Aduen et al. found PE in 52% of the patients undergoing LT. 3 Immediate PE occurred in 25% of the patients, 9% had late PE (developing de novo in the first 16 to 24 hours), and 18% had persistent PE (developing immediately and persisting for at least 16 hours). Immediate PE had little clinical consequence, resolving within 24 hours, but persistent permeability-type PE portended a worse outcome. This diffuse edema has been attributed to multiple etiologies: fluid overload, transfusion-related acute lung injury (TRALI), acute respiratory distress syndrome (ARDS), and PE associated with fulminant hepatic failure. 2 The underlying pathophysiologic disturbances involve either an imbalance in the transcapillary hydrostatic forces (hydrostatic-type PE) or a disruption of the permeability barrier (permeability-type PE).A rare cause of noncardiogenic PE is a form of a nondiffuse type of pulmonary endothelial injury that occurs following rapid air expansion of a collapsed lung, the so-called reexpansion pulmonary edema (REPE). 4 In the LT setting, large pleural effusions are a common finding and are frequently evacuated during the procedure. It is well recognized that the rapid evacuation of large volumes of air or fluid from the pleural space can cause REPE with variable clinical significance. However, this complication after LT was only reported by Jabber et al., who described a single case with a benign course. 5 Herein, we report an overwhelming perioperative REPE during a LT that rapidly led to the patient's demise and speculate if this condition has not been underrecognized in the LT setting. Case ReportA 47-year-old male farmer with Child-Turcotte-Pugh C cirrhosis secondary to recurrent hepatitis B underwent hepatic retransplantation. Preoperative cardiovascular and respiratory work-up showed only moderate right pleural effusion. After induction of the anesthesia, the ventilator was set to conventional parameters (fraction of inspired oxygen: 40%; positive end-expiratory pressure, 5 cm H 2 O) and 2 large-bore central catheters were placed into the right internal jugular vein. Arterial blood gases and hemodynamic measurements were within the normal ra...

The impact of preoperative hepatic hydrothorax on the outcome of adult liver transplantation

“…However, there are several arguments to suspect that preoperative hepatic hydrothorax may negatively influence the postoperative course of OLT. Potential negative impacts of this pleural effusion may include the development of a postoperative reexpansion pulmonary edema [23], postoperative persistence of hydrothorax, and potential infectious complications [24][25][26]. The results of this study reinforce that the postoperative course of patients with preoperative hepatic hydrothorax is comparable with cirrhotic patients without this affection.…”

Intensive Care of Pulmonary Complications Following Liver Transplantation

“…74,76 Other mechanisms of permeability-type pulmonary edema occurring post-liver transplantation include transfusion-related acute lung injury [77][78][79][80][81] and was seen more frequently after calcineurin inhibitors came into use 81,82 as well as fast tapering of steroids 79 and less commonly, reexpansion. 81,83 There is no significant difference between whether the edema resolved or persisted between hydrostatic-type and permeability-type pulmonary edema. 74 Moreover, the duration on mechanical ventilation, LOS in the ICU, and LOS in the hospital were shown to be not significantly different between patients with immediate pulmonary edema and patients with no pulmonary edema.…”

“…74,76 Other mechanisms of permeability-type pulmonary edema occurring post-liver transplantation include transfusion-related acute lung injury 77 -81 and was seen more frequently after calcineurin inhibitors came into use 81,82 as well as fast tapering of steroids 79 and less commonly, reexpansion. 81,83…”

A Case of Severe Tricuspid Valve Regurgitation in a Patient Undergoing Orthotopic Liver Transplantation: Whether to Proceed, or Not

“…In the absence of intraoperative TEE, any significant improvements in MPAP could have misled one to believe the elevation was a temporary manifestation of Trendelenburg positioning and/or fluctuating depth of anesthesia in the setting of intravascular volume overload. If the surgery had proceeded, the effects of cross-clamp release during the reperfusion period on the cardiopulmonary circulation may have been catastrophic, as the stress of reperfusion on an already compromised right ventricle would have likely resulted in cardiopulmonary failure, graft congestion and failure, and death [8][9][10][11][12].…”