BACKGROUND: Intraoperative hypotension (IOH) occurs frequently during surgery and may be associated with organ ischemia; however, few multicenter studies report data regarding its associations with adverse postoperative outcomes across varying hemodynamic thresholds. Additionally, no study has evaluated the association between IOH exposure and adverse outcomes among patients by various age groups. METHODS: A multicenter retrospective cohort study was conducted between 2008 and 2017 using intraoperative blood pressure data from the US electronic health records database to examine postoperative outcomes. IOH was assessed in 368,222 noncardiac surgical procedures using 5 methods: (a) absolute maximum decrease in mean arterial pressure (MAP) during surgery, (b) time under each absolute threshold, (c) total area under each threshold, (d) time-weighted average MAP under each threshold, and (e) cumulative time under the prespecified relative MAP thresholds. MAP thresholds were defined by absolute limits (≤75, ≤65, ≤55 mm Hg) and by relative limits (20% and 40% lower than baseline). The primary outcome was major adverse cardiac or cerebrovascular events; secondary outcomes were all-cause 30- and 90-day mortality, 30-day acute myocardial injury, and 30-day acute ischemic stroke. Residual confounding was minimized by controlling for observable patient and surgical factors. In addition, we stratified patients into age subgroups (18–40, 41–50, 51–60, 61–70, 71–80, >80) to investigate how the association between hypotension and the likelihood of major adverse cardiac or cerebrovascular events and acute kidney injury differs in these age subgroups. RESULTS: IOH was common with at least 1 reading of MAP ≤75 mm Hg occurring in 39.5% (145,743) of cases; ≤65 mm Hg in 19.3% (70,938) of cases, and ≤55 mm Hg in 7.5% (27,473) of cases. IOH was significantly associated with the primary outcome for all age groups. For an absolute maximum decrease, the estimated odds of a major adverse cardiac or cerebrovascular events in the 30-day postsurgery was increased by 12% (95% confidence interval [CI], 11-14) for ≤75 mm Hg; 17.0% (95% CI, 15-19) for ≤65 mm Hg; and by 26.0% (95% CI, 22-29) for ≤55 mm Hg. CONCLUSIONS: IOH during noncardiac surgery is common and associated with increased 30-day major adverse cardiac or cerebrovascular events. This observation is magnified with increasing hypotension severity. The potentially avoidable nature of the hazard, and the extent of the exposed population, makes hypotension in the operating room a serious public health issue that should not be ignored for any age group.

Five-year mortality and graft loss in older recipients were comparable with those in younger recipients, suggesting that age alone should not exclude older patients from liver transplant.

We investigated the clinical significance of time of onset, duration, and type of pulmonary edema after orthotopic liver transplantation by retrospectively reviewing 93 consecutive recipients. Pulmonary edema was diagnosed by means of radiographic criteria and PaO 2 /FIO 2 ratio <300. Type was identified by pulmonary artery wedge pressure (hydrostatic, >18 mm Hg; permeability, <18 mm Hg O rthotopic liver transplantation is an accepted treatment for patients with end-stage liver disease. Survival after transplantation has been improving steadily, with a current one-year survival rate of 86.9% for patients and 81.3% for grafts. 1 Nonetheless, early pulmonary complications are common and known to contribute significantly to morbidity and mortality. 2 The most frequent pulmonary complications are pleural effusion, atelectasis, pulmonary edema, and pneumonia. [3][4][5] Pulmonary edema occurs in 14% to 47% of liver transplant recipients. [6][7][8][9][10] It is diagnosed clinically by the combination of bilateral radiographic infiltrates and impaired oxygenation. 11 The purpose of this study was to investigate the clinical significance of the time of onset and the duration of pulmonary edema after orthotopic liver transplantation in consecutive liver transplant recipients. In addition, we investigated whether the traditional classification of pulmonary edema 12 into hydrostatic or permeability types is associated with different outcomes. Methods Patients and Transplantation ProceduresThe medical records of all consecutive patients who underwent orthotopic liver transplantation at Mayo Clinic, Jacksonville, Florida, from February 25, 1998, to October 1, 1999, were retrospectively reviewed. This series represents the first 93 consecutive liver transplant recipients in our transplantation program.All liver transplantation procedures were performed using the piggyback technique without venovenous bypass. Pulmonary arterial catheters were inserted intraoperatively to facilitate hemodynamic management. Patients routinely received small amounts of epinephrine boluses at the time of graft reperfusion but had no sustained need for vasoconstrictor or inotropic support. Decisions regarding administration of fluids and blood products were made according to standards for care to provide hemodynamic stability and correction of unexpected coagulation abnormalities and bleeding. All patients were admitted to the intensive care unit (ICU) immediately after surgery and then extubated as soon as they met standard criteria for termination of mechanical ventilation, such as presence of adequate gas exchange function, hemodynamic stability, and ability to protect the airway. Pulmonary EdemaRadiographic, arterial oxygenation, and hemodynamic data were collected to evaluate patients for pulmonary edema preoperatively on the day of surgery and postoperatively on admission to the ICU and 16 to 24 hours after the operation. A chest radiologist and two pulmonary intensivists evaluated