Koep, L

Mazzoni, G

Starzl, TE

PubMed

Name not available

Air embolus in liver transplantation

D-Scholarship@Pitt

. n° At. '. ,. d with ithelial 1 wash-clion at lated in • n in an r mective • -ing the I • I: Surgery )Iantalion. 1978 al: Trans-C, et al: .. Air Embolus in Liver Transplantation G. Mazzoni, l. Koep, and T. Starzl AMONG adult recipients of orthotopic liver homografts, a high incidence of acute and profound neurologic disability has been recognized shortly after operation.'-z A clinical neuropathologic survey of these central nervous system complications has been reported in detail2 and will be summa-rized her~ Particular emphasis has been placed on the possible etiologic role of air emboli originating from the btpatic homo-graft and on the avoidance of such emboli. MATERIAlS AND METHODS Forty-eight adult patients were treated between March 1963 and April 1976. Within the group of 48 adults. 9 patients sustained eliaally significant neurologic dam-age during or soon after operation. All 9 patients had end-stage cirrhosis aad evidence of portal hyperl~!lgion_ Three were alert just prior to operation. The other six had evidence or altered consciousness, ranging between confusion and coma. Postoperatively, all nine patients developed irreversible and widespread neurologic dam-age. which contributed to or caused death. During the life or these patients. clear identification of the causative factors or these complications was not possible_ Standard li\lCr functions tests usually were not very abnormal. 11Iere was no evidence in any patient of early posttransplantation liver necrosis. Cerebral angio-graphy in one patient suggested throm1x-tic or embolic disease. However, moll coagulation ractors in this and other patients, as extmplified by the prothrombin time. were only moderately subnormal. Cortical ischemia area with dying neurons and microcystic changes. gliosis related to demyelimination. capillary proliferation,' injured neurons. and &1iosis were noted in almost all our cases . EVIDENCE OF AIR EMBOLUS Although the neuropathologic changes could have been caused by air embolus, they were nonspecific. However, evidence of air embolus was definitely observed in some cases, including one of our early patients who developed bilateral partial leg paralysis. Another patient bad a cardiac arrest from which he was promptly resuscitated. Air was withdrawn from a right atrial catheter imme-diately afterwards. Transplantation 1'rocee6I1fIS. Vol. XI. No. 1 (Marchi. 1979 Another patient awakened promptly after transplantation and was completely normal for several hours. He then suddenly had a focal seizure, never regained consciousness, and d,ied 2 days later. At autopsy, the cav-ernous sinus and several Cerebral arteries contained gross air. PATHOPHYSIOLOGY OF AIR EMBOLUS Thus, cerebral air embolism, derived from residual air in the homograft vena cava or hepatic veins, was suspected to have been responsible for at least some of the neurologic complications. Appreciation of this concept has been slow and delayed by an imprecise understanding of how air could regularly by-pass the lung, go to the left heart and systemic circulation, and then proceed to th~ brain. In actuality, the ability of the air to readily cross the lung barrier is understandable. Even in normal human lungs, potential connections exist between the pulmonary artery and venules. These anastomotic channels become patent under various conditions and particu-larly with chronic liver disease. In addition, communications may exist between the portal. and azygos veins. It appears reasonable to believe that air could easily make its way by anyone of several routes to the systemic circulation and lodge within the central nervous system, producing From the Department 0/ Surgery. Denver Veterans Administration Hospital and the University o/Colorado Medical Centt'T. Denver. Colo. Supported in part by research grants from the VA Hospital. Denver. Colo.: by NIH Grants AM-J7160 and AM-07772; and by Grants RR-00051 and RR-00069 from the GeMral Clinical Research Centers Program 0/ the Dil/ision 0/ Research Resources. NIH. Reprint requests should be addresstd to T. Storz/. Depal1melll o/Surgtry. Denvtr Vtttrans Administration HOSpital. Denver. Colo. e 1979 by GruM & Strallon. Inc. (J(U1-IJ45/79/IIOI-0058S01.00/0 267 268 focal damage. In patients with the right-to-left shunts of liver disease. air presumably could quickly by-pass the lungs. enter the pulmonary veins and left heart. and by lodg-ing in these latter locations. could remain a threat to the brain and other organs for many hours or even days. The fact that air bubbles may persist for a long time before' a fatal movement to the brain could explain the lucid interval in some of our patients before the onset of seizures. paralysis. and coma. PREVENTION OF AIR EMBOLI An infusion technique now being used during liver transplantation apparently has eliminated the sOurce of air emboli in the MAZZONI. KOEP, AND STARZI.. high-risk adult patients. The portal perfusion that is used to chill the organ is continued as the upper and lower vena caval anastomoses are performed. care being taken to float out any residual bubbles as the anastomoses are completed.2 The portal venous and hepatic arterial anastomoses are then performed in the usual way. With revascularization, after completion of either three or all four anasto-moses. the anesthesiologist has listened with the esophageal stethoscope for auscultatory evidence of air embolization. None has been detected since the use of this technique. Furthermore. no neurologic complications have been encountered in the additional 28 adults so treated since April 1976. REFERENCES I. Staizl TE. Schneck. S. Mazzoni G. et al: Ann Surg 2. Starzl TE. ·Porter KA. Putnam CW, et al: Surg 2:184, 1978 . GynecolObstet 142:487, 1976 ~ , , I .. J , , I .. I I M ORI Sta first succe man. 1 Cal plary seril since For successful plant.) As the Tram plants hay have, of C( of cases. C topic grar Nineteen 1 longest SI being 82/3: one patien and well ~ patients i heterotopi months, r topic grar to 34 days although are suftie analysis. T( The rei space in I types of particulal ient's OWl the orth, induced can provi l heterotop not great is not fea obtained synthetic approach lobe or tt Transplanta 

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Air embolus in liver transplantation

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