HEMODYNAMIC CORRELATES OF OUTCOME IN PATIENTS UNDERGOING ORTHOTOPIC LIVER-TRANSPLANTATION - EVIDENCE FOR EARLY POSTOPERATIVE MYOCARDIAL DEPRESSION

Objective: To describe the hemodynamic and oxygen transport patterns in survivors and nonsurvivors following liver transplantation (LT) and to assess their relationship to organ failure and mortality. Design: Retrospective cohort. Setting: Surgical ICU in a tertiary care university teaching hospital. Patients: Consecutive series of 113 adults undergoing LT between 1984 and 1992. Patients were excluded if they died intraoperatively (n=2), required retransplantation (n=8), or their records were incomplete (n=7). Measurements and main results: Preoperative severity of illness was assessed by the acute physiology and chronic health evaluation (APACHE) II scoring system. Hemodynamic and oxygen transport variables were recorded immediately preoperatively and sequentially every 12 h during the first 2 postoperative days. Organ failures (pulmonary, renal, cardiovascular, hepatic, and central nervous system) were assessed for patients in the postoperative period. Patients were grouped as survivors (n=82) or nonsurvivors (n=14) with a mortality rate of 15%. Preoperative APACHE II scores were significantly lower in survivors compared with nonsurvivors (7+/-0 vs 11+/-2; p=0.029). Both preoperatively and postoperatively, survivors sustained a relatively higher mean arterial pressure, stroke volume index, left ventricular stroke work index, cardiac index, and oxygen delivery as compared with nonsurvivors (p<0.01). The postoperative decline in systemic blood flow that was seen in both groups was particularly prominent in nonsurvivors during the first 12 h following LT (p<0.03). Nonsurvivors sustained an approximately fivefold increase in the rate of organ failure (p<0.0001); all patients (n=6) with 4 or more organ failures died. Conclusion: Nonsurvivors of LT have less cardiac reserve pretransplant; postoperatively, they demonstrate early myocardial depression and subsequently lower levels of cardiac index and oxygen delivery. Patients who develop these hemodynamic patterns are more prone to organ failure and death.