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 i n survivors and nonsurvivors following liver transplantation (LT) and to assess their relationship to organ failure and mortality. Design: R etrospective cohort. Setting: Surgical ICU in a tertiary care universi ty teaching hospital. Patients: Consecutive series of 113 adults under going LT between 1984 and 1992. Patients were excluded if they died in traoperatively (n=2), required retransplantation (n=8), or their recor ds were incomplete (n=7). Measurements and main results: Preoperative severity of illness was assessed by the acute physiology and chronic h ealth evaluation (APACHE) II scoring system. Hemodynamic and oxygen tr ansport variables were recorded immediately preoperatively and sequent ially every 12 h during the first 2 postoperative days. Organ failures (pulmonary, renal, cardiovascular, hepatic, and central nervous syste m) were assessed for patients in the postoperative period. Patients we re grouped as survivors (n=82) or nonsurvivors (n=14) with a mortality rate of 15%. Preoperative APACHE II scores were significantly lower i n survivors compared with nonsurvivors (7+/-0 vs 11+/-2; p=0.029). Bot h 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 fl ow that was seen in both groups was particularly prominent in nonsurvi vors during the first 12 h following LT (p<0.03). Nonsurvivors sustain ed an approximately fivefold increase in the rate of organ failure (p< 0.0001); all patients (n=6) with 4 or more organ failures died. Conclu sion: Nonsurvivors of LT have less cardiac reserve pretransplant; post operatively, they demonstrate early myocardial depression and subseque ntly lower levels of cardiac index and oxygen delivery. Patients who d evelop these hemodynamic patterns are more prone to organ failure and death.