Early respiratory complications after liver transplantation

Table 1 Common preoperative risk factors for post-orthotopic liver transplantation pulmonary complications

Recipient’s age[2,8]

Female sex[5]

Smoking history[3]

Severity of liver dysfunction[2] (Child-Pugh class[5], MELD score[12,43])

Cirrhotic encephalopathy

Cerebral dysfunction[5]

Acute renal failure

Emphysema[3]

High systolic pulmonary artery pressure[3]

Hypoxia, orthodeoxia[3]

Hepatopulmonary syndrome

Pre-existing pulmonary abnormalities[1]:

Intrinsic cardiopulmonary disease: chronic obstructive pulmonary disease, congestive heart failure, pneumonia, asthma

Specific to liver disease: association with specific liver diseases (alpha-1 antitrypsin deficiency, primary biliary cirrhosis), fluid retention com plicating portal hypertension (ascites, hepatic hydrothorax), pulmo- nary vascular abnormalities (hepatopulmonary syndrome, portopul monary hypertension)

Evidence of a restrictive pulmonary syndrome[2]

Abnormal spirometry findings[3]

Preoperative ventilator support[6]

Severe preoperative respiratory failure requiring mechanical ventilation[8,9]

Higher value of INR[2]

Preexisting diabetes mellitus[6,7]

Impaired renal function[6]

Preoperative MARS use[6]

Deceased donor source of organ transplantation[6]

MELD: Model End Stage Liver Disease; INR: International normalised ratio; MARS: Molecular adsorbent re-circulating system.

Table 2 Major intraoperative and common postoperative risk factors for post-orthotopic liver transplantation pulmonary complications

Major intraoperative risk factors

Surgical procedure[2] (wide incision[19])

Intraoperative fluid transfusion volume[2,8,12]

Intraoperative blood transfusion volume[6,12]

Perioperative fluid balance[12]

Intraoperative fluid retention[14]

Intraoperative bleeding volumes[14]

Common postoperative risk factors

Excessive perioperative fluid administration[2]

Postoperative duration of mechanical ventilation[2] (delayed removal of endotracheal tube[13,19])

Acute rejection during the hospital stay[2]

Postoperative acute renal failure[5]

Postoperative hypoproteinemia

Onset of renal insufficiency

Poor postoperative myocardial function

Right hemidiaphragm paralysis[24]

Greater exposure to nosocomial agents[34]

Significant decline in the recipient’s immune function[34]

Surgical complications[34]

Re-interventions or need for retransplantation[34]

Table 3 Major post-orthotopic liver transplantation pulmonary complications

Complication	Frequency
Pleural effusion[4,8,12,30]	32%-47%
Atelectasis[8,12,28,30]	5%-29%
Pulmonary edema[8,12-14,28,30]	4%-47%
Acute respiratory distress syndrome[4,8,9,12,14,28,30,55]	0.8%-42%
Pneumonia[2,4,8,12,14,28,30,36-39]	5%-38%

Table 4 Major strategies to prevent postoperative pulmonary complications after orthotopic liver transplantation

Preoperative strategies	Intraoperative strategies
Pulmonary rehabilitation prior to OLT	Reduction in the degree of surgical insult
	Reduction in the level of aggressiveness
	Reduction in the duration of procedure
	Reduction in the amount of blood lost
Postoperative ventilation[60,61,64,65]	Postoperative care[68]
Early extubation	Adequate postoperative pain relief Optimal hemodynamic and fluid management Improvement of general health and nutrition
Lung expansion maneuvers
Deep breathing exercises
Timely execution of bronchial toilette
NIV
Chest percussion and vibration
Invasive mechanical ventilation: assisted modes with minimal sedation

OLT: Orthotopic liver transplantation; NIV: Non-invasive ventilation.