Infezioni polmonari precoci dopo trapianto epatico ortotopico

Aim of the study - Retrospectively reviewing a series of 69 consecutive patients who underwent OLT, we have studied the incidence of early pulmonary infections, the associated morbidity and mortality and which independent clinical variables occurring in the perioperative period could be considered as a risk factor for pulmonary infections. Design: retrospective study. Setting: intensive Care Unit, Niguarda Ca' Granda Hospital, Milan. Methods: sixty-nine patients (22 females and 47 males , mean age 49 ± 7 years) who underwent consecutive OLT for ESLD from June 1995 to Dec 1996 and survived more than 48 hours posttransplant were studied. Results: sixteen patients (23%) had sixteen episodes of pulmonary infections during the first 3 weeks following OLT. Gram positive microorganisms (MO) were responsible in 9 cases, Gram negative in 3, Gram positive and Candida in 2, Gram positive and Gram negative in 2. In 75% of the cases pulmonary infections were associated with acute postoperative respiratory failure and needed prolonged mechanical ventilation. Four patients (25%) died with pulmonary infections and respiratory failure as part of a multiple organs dysfunction (MODS) secondary to severe hepatic failure: pulmonary infections however were never considered as primary cause of death. At univariate analysis, risk factors for pulmonary infections were Child C Class (p = 0.009); duration of surgery (>15 hours , p = 0.004); graft ischemia time (>13 hours, p = 0.038); blood loss (>15 liters , p = 0.003) ; transfusion requirements (PRC > 30 units, p = 0.05; FFP > 40 units, p = 0.012); PaO2 / FiO2 < 250 (p = 0.000) ; postoperative ventilatory support (mechanical ventilation > 6 days, p = 0.01) ; marginal function of the graft (bilirubinemia ≥ than 15 mg dl-1, p = 0.05; lactate blood levels at POD 3 ≥ 3 mMol L-1, p = 0.05; aPTT ≥ 30 secs on POD 3); renal failure (p = 0.009); use of CVVH (p = 0.000) ; relaparotomies for hemoperitoneum (p = 0.006). Conclusions: from our data we can conclude that the incidence of pulmonary infections in our series is still high, if compared to the results obtained in other studies, but with a less severe impact on the outcome. Intraoperative surgical technical problems, possibly correlated with the advanced liver disease, have, in the early postoperative period, a distinct impact on ventilation, gas exchange, hemodynamic equilibrium, renal function.