Postreperfusion Cardiac Arrest and Resuscitation During Orthotopic Liver Transplantation: Dynamic Visualization and Analysis of Physiologic Recordings

Intraoperative Cardiac Arrest During Adult Liver Transplantation: Incidence and Risk Factor Analysis From 7 Academic Centers in the United States

BACKGROUND

Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks.

METHODS

Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes.

RESULTS

ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI) <20 (odds ratio [OR]: 2.04, 95% CI, 1.05-3.98; P = .0386), BMI ≥40 (2.16 [1.12-4.19]; P = .022), Model for End-Stage Liver Disease (MELD) score: (MELD 30-39: 1.75 [1.09-2.79], P = .02; MELD ≥40: 2.73 [1.53-4.85], P = .001), postreperfusion syndrome (PRS) (3.83 [2.75-5.34], P < .001), living donors (2.13 [1.16-3.89], P = .014), and reoperation (1.87 [1.13-3.11], P = .015). Overall 30-day and 1-year mortality were 4.18% and 11.0%, respectively. After ICA, 30-day and 1-year mortality were 43.9% and 52%, respectively, compared to 2.6% and 9.3% without ICA.

CONCLUSIONS

We established a 3.7% incidence of ICA and a 1.2% incidence of intraoperative mortality in liver transplantation and confirmed previously identified risk factors for ICA including BMI, MELD score, PRS, and reoperation and identified new risk factors including living donor and length of surgery in this multicenter retrospective cohort. ICA, while rare, is associated with high intraoperative mortality, and future research must focus on therapy to reduce the incidence of ICA.

Expanded Criteria Donor-Related Hyperkalemia and Postreperfusion Cardiac Arrest During Liver Transplantation: A Case Report and Literature Review

Background

Liver transplantation (LT) using extended criteria donor (ECD) grafts is frequently associated with a high flush fluid potassium concentration (FFK) and acute hyperkalemia after reperfusion, which puts patients at greater risk of postreperfusion cardiac arrest (PRCA).

Case Report

Herein, we present a case with an extremely high FFK that was successfully pretreated to avoid the risk of PRCA. A 3-year-old boy with biliary atresia underwent LT from a 623-g donation after brain death liver graft with localized frostbite on the right lobe surface. The FFK was 18.8 mmol/L after flushing with 1000 mL of 5% albumin. To prevent PRCA due to acute hyperkalemia, further portal vein (PV) flush, retrograde reperfusion via the inferior vena cava, and antegrade reperfusion via the PV were adopted to remove the excessive potassium ions. Ultimately, the liver graft was reperfused when the perfused blood potassium concentration was 7.5 mmol/L without subsequent development of PRCA during the immediate reperfusion period. Nevertheless, the patient still experienced vasoplegic syndrome during the late reperfusion period.

Conclusions

Our case illustrates that the FFK measurement is helpful for identifying ECD-related hyperkalemia and for providing advance warning of PRCA. Future investigations are warranted to confirm the relationship between high FFK and PRCA and to observe the effectiveness of other interventions to prevent PRCA due to ECD-related hyperkalemia.