Systemic Hemodynamic and Cardiac Function Changes in Patients Undergoing Orthotopic Liver Transplantation* Frederick L. Glauser; M. D.
The objective of this study was to determine the changes in systemic hemodynamics (systemic vascular resistance [SVR], cardiac output [CO], systemic blood pressure [SBP]) and cardiac function (pulmonary artery pressure [PAP] and pulmonary wedge pressure [PWP]) during the 96 hours following orthotopic liver transplantation (OLT) and correlate these with changes in hepatic and renal function and patient outcome. The study took place in a I2-bed medical respiratory intensive care unit in a large teaching hospital. Twenty-one patients had OLT performed over a 21.5month period Oanuary 1988 to October 15, 1989) for end stage liver disease (ESLD) from a variety of causes. A Bowdirected right heart catheter and an indwelling arterial cannula were inserted for hemodynamic monitoring over a 96-hour postoperative period. Liver and renal function studies, total serum calcium, serum albumin, and Buid balance were determined daily. The SVR increased significantly to 12.8 ± 0.6 U at 48 hours compared with immediate «8 hours) postoperative levels (p70 percent of the patients are out of the hospital when a suitable liver is found and thus, preoperative hemodynamic data are available only in a small percentage of patients). The cause(s) of the ESLD, any complications, length of the OLT operation, estimated blood loss, and the various Ouids administered intraoperatively were recorded. Postoperatively, on entry to the MRICU, hemodynamics were obtained every 8 h for 96 h (although this time was often less for Swan-Ganz data since, in a certain percentage of patients, this catheter was removed prior to this time limit). Selected liver and renal function studies and serum calcium and albumin levels were obtained at least daily. Since hemodynamic status 8uctuated in many patients for several hours after admission to the MRICU, "baseline" postoperative values were arbitrarily defined as follows: two consecutive values taken 1 h apart that were within 10 percent of each other during the first 8 h after entering the MRICU. This first value is designated as CCbaseline" and preoperative and all subsequent values (hours 16 through 96) are compared with this baseline measurement. Calculations
SVR = PVR = LVSW RVSW
(SBP - RAP)/CO = units (Wood) (PAP - PWP)/CO - units (Wood) = COIHR X (systolic BP - PWP) X .0136 = g.m = COIHR X (systolic PAP - RAP) X .0136 = g.m
Postoperative Medications
The majority ofthe patients (15 of21) received low-dose dopamine intravenously (iv) to maintain renal and hepatic blood Oovv. Immunosuppressive drugs included antithymocyte globulin, methylprednisolone, azathioprine, and cyclosporine (starting on postoperative day 3 to 6). A 50 percent albumin solution (25 g in 50 ml) is administered every 8 h for the first three to four days and then as necessary, depending on serum albumin levels. Fresh frozen plasma is administered to maintain a normal or slightly increased (ie, 1- to 2-s prolongation) prothrombin time. In addition, nitroprusside, nitroglycerin, morphine sulfate, etc, may be ordered by the attending physician when clinically indicated.
Table I-Cardiac and Hemodynamic
Statistical Analysis
A STATPAK Multifunction Statistical Library Program (Northwest Analytical Co, Portland, are) was used on a computer (Epson Equity I +). A two-way analysis of variance, where applicable, was employed to determine intergroup and intragroup differences. When a difference was found, paired or unpaired modified Student's t test, where appropriate, was employed. The STATPAK Program has a subprogram that corrects for data that are not normally distributed. Regression analysis and correlation coefficients for comparing various parameters were also determined: ± = standard error; p (/)
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had repair of the right hemidiaphragm that was inadvertently injured during surgery and two patients had insertion of right-sided chest tubes for pneumothorax experienced during surgery.
48
72
96
POSTOP, HRS
FICURE 1. Changes in systemic vascular resistan
The objective of this study was to determine the changes in systemic hemodynamics (systemic vascular resistance [SVR], cardiac output [CO], systemic blood pressure [SBP]) and cardiac function (pulmonary artery pressure [PAP] and pulmonary wedge pressure [PWP]) during the 96 hours following orthotopic liver transplantation (OLT) and correlate these with changes in hepatic and renal function and patient outcome. The study took place in a I2-bed medical respiratory intensive care unit in a large teaching hospital. Twenty-one patients had OLT performed over a 21.5month period Oanuary 1988 to October 15, 1989) for end stage liver disease (ESLD) from a variety of causes. A Bowdirected right heart catheter and an indwelling arterial cannula were inserted for hemodynamic monitoring over a 96-hour postoperative period. Liver and renal function studies, total serum calcium, serum albumin, and Buid balance were determined daily. The SVR increased significantly to 12.8 ± 0.6 U at 48 hours compared with immediate «8 hours) postoperative levels (p70 percent of the patients are out of the hospital when a suitable liver is found and thus, preoperative hemodynamic data are available only in a small percentage of patients). The cause(s) of the ESLD, any complications, length of the OLT operation, estimated blood loss, and the various Ouids administered intraoperatively were recorded. Postoperatively, on entry to the MRICU, hemodynamics were obtained every 8 h for 96 h (although this time was often less for Swan-Ganz data since, in a certain percentage of patients, this catheter was removed prior to this time limit). Selected liver and renal function studies and serum calcium and albumin levels were obtained at least daily. Since hemodynamic status 8uctuated in many patients for several hours after admission to the MRICU, "baseline" postoperative values were arbitrarily defined as follows: two consecutive values taken 1 h apart that were within 10 percent of each other during the first 8 h after entering the MRICU. This first value is designated as CCbaseline" and preoperative and all subsequent values (hours 16 through 96) are compared with this baseline measurement. Calculations
SVR = PVR = LVSW RVSW
(SBP - RAP)/CO = units (Wood) (PAP - PWP)/CO - units (Wood) = COIHR X (systolic BP - PWP) X .0136 = g.m = COIHR X (systolic PAP - RAP) X .0136 = g.m
Postoperative Medications
The majority ofthe patients (15 of21) received low-dose dopamine intravenously (iv) to maintain renal and hepatic blood Oovv. Immunosuppressive drugs included antithymocyte globulin, methylprednisolone, azathioprine, and cyclosporine (starting on postoperative day 3 to 6). A 50 percent albumin solution (25 g in 50 ml) is administered every 8 h for the first three to four days and then as necessary, depending on serum albumin levels. Fresh frozen plasma is administered to maintain a normal or slightly increased (ie, 1- to 2-s prolongation) prothrombin time. In addition, nitroprusside, nitroglycerin, morphine sulfate, etc, may be ordered by the attending physician when clinically indicated.
Table I-Cardiac and Hemodynamic
Statistical Analysis
A STATPAK Multifunction Statistical Library Program (Northwest Analytical Co, Portland, are) was used on a computer (Epson Equity I +). A two-way analysis of variance, where applicable, was employed to determine intergroup and intragroup differences. When a difference was found, paired or unpaired modified Student's t test, where appropriate, was employed. The STATPAK Program has a subprogram that corrects for data that are not normally distributed. Regression analysis and correlation coefficients for comparing various parameters were also determined: ± = standard error; p (/)
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Systemic Hemodynamics, Cardiac Function, and Fluid Balance
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had repair of the right hemidiaphragm that was inadvertently injured during surgery and two patients had insertion of right-sided chest tubes for pneumothorax experienced during surgery.
48
72
96
POSTOP, HRS
FICURE 1. Changes in systemic vascular resistan
