Study objectives: To describe the clinical features of
a group of patients who acutely developed pulmonary edema during
orthotopic liver transplantation and to determine the nature
(transudate vs exudate) of the edema.
Retrospective review of clinical records and radiographic studies.
Setting: Operating room and ICU of a tertiary-care medical
Patients: End-stage liver disease
patients undergoing orthotopic liver transplantation under general
Interventions and measurements: Pulmonary
edema fluid obtained from seven patients within 15 min of first
appearance was analyzed for protein content and compared with the
protein content of a simultaneously obtained plasma sample. Hemodynamic
data, fluid administration totals, and length of postoperative
intubation and ICU stay were also collected.
Eight patients were identified. Six of the seven patients whose edema
fluid was analyzed had edema fluid/plasma protein ratios ≥ 0.75,
characteristic of increased permeability pulmonary edema (the one other
patient had a ratio of 0.73). Hemodynamic monitoring at the time of
onset of the edema effectively ruled out a cardiogenic etiology. One
patient died intraoperatively; at autopsy, the cause of death was
determined to be pulmonary fat embolization. In the other seven
patients, production of edema fluid resolved within 6 h of
admission to the ICU. The duration of ventilatory support ranged from
23 to 96 h, with a mean of 49 h.
Conclusions: The most likely cause of the reaction is
transfusion-related acute lung injury (TRALI). An incidence of TRALI
that is higher than previously reported in this population indicates
that other elements, such as reperfusion of the newly implanted liver,
may be contributing factors.