Incidence and Clinical Outcomes of Ventilator-Associated Pneumonia in Liver Transplant and Non-Liver Transplant Surgical Patients

Pellegrino, Carmen; Codeluppi, Mauro; Assenza, S.; Cocchi, Stefania; Benedetto, Fabrizio Di; Girardis, Massimo

doi:10.1016/j.transproceed.2008.05.022

Cited by 13 publications

(7 citation statements)

References 9 publications

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“…[25][26][27][28][29] Our rate of 15.5% among liver recipients agrees with previously reported rates of pneumonia after LT ranging from 5% to 34%. [4][5][6][7][8][9][10]30 Two recent studies showed a rate of pneumonia of 21.1% in liver recipients receiving a 3-day prophylactic regimen of CTX and ampicillin and a rate of 18% in living donor-related recipients receiving selective digestive decontamination. 6,9 Routine, prolonged prophylactic antibiotic treatment and selective digestive decontamination were not administered in our population.…”

Section: Discussionmentioning

confidence: 99%

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Weiss¹,

Dahmani²,

Bert³

et al. 2010

Liver Transpl

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Early-onset hospital-acquired pneumonia (E-HAP) is one of the leading causes of sepsis and mortality after liver transplantation (LT). The appropriate antimicrobial therapy is crucially important for surviving sepsis in this context. The aim of this study was to analyze microbiological findings, associated factors, and optimal antibiotic regimens for E-HAP after LT. Patients demonstrating E-HAP in a single-center cohort of 148 LT recipients were prospectively detected. The diagnosis of pneumonia relied on a combination of supportive clinical findings and a positive culture of a lower respiratory tract sample. E-HAP was considered present if pneumonia occurred within 6 days of intensive care unit (ICU) admission after LT. Twenty-three patients (15.5%) developed E-HAP, which were caused by 36 pathogens (61.1% were gram-negative bacilli, and 33.3% were classified as hospital-acquired). For patients who developed E-HAP, the duration of mechanical ventilation and the ICU stay were significantly longer. Despite a trend toward higher mortality at any time in the E-HAP group, there was no significant difference in mortality between patients with E-HAP and patients without E-HAP. Lactatemia, vasopressor requirements, Simplified Acute Physiology Score II (SAPS II) score on ICU admission, and mechanical ventilation lasting more than 48 hours after LT were associated with E-HAP. Combinations of broad-spectrum b-lactams and aminoglycosides were active against more than 91% of the encountered pathogens. However, antibiotic de-escalation was possible in more than one-third of cases after identification of the pathogens. In conclusion, E-HAP after LT is a severe condition that appears to be influenced by physiological derangements induced by the surgery, such as lactatemia, vasopressor requirements, and mechanical ventilation requirements, as well as the postoperative SAPS II score. At the time of treatment initiation, an antimicrobial regimen usually proposed for late-onset pneumonia should be followed. Orthotopic liver transplantation (LT) is a widely accepted treatment for patients with end-stage liver disease. Despite global improvements in survival over the last few decades, sepsis remains the leading cause of early postoperative mortality. 1,2 Lower respiratory tract infections are a major concern in this context.

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Section: Discussionmentioning

confidence: 99%

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Weiss¹,

Dahmani²,

Bert³

et al. 2010

Liver Transpl

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“…Although, as noted, severe hypoxemia is out of proportion to concurrent lung pathologies by definition, a number of other pulmonary changes likely incrementally impair gas exchange in the postoperative period, particularly with prolonged intubation. These include atelectasis, simple ventilator‐related changes such as increased dead space due to the overventilation of susceptible lung units, physiological shunting due to underventilation or heterogeneous gas distribution, and complications such as VAP, which was seen in all 4 of our patients (in contrast to approximately 25% of routine LT cases) . All of these exacerbate VQ mismatch through a mechanism distinct from that of HPS by primarily affecting ventilation rather than perfusion.…”

Section: Discussionmentioning

confidence: 85%

“…These include atelectasis, simple ventilator-related changes such as increased dead space due to the overventilation of susceptible lung units, physiological shunting due to underventilation or heterogeneous gas distribution, and complications such as VAP, which was seen in all 4 of our patients (in contrast to approximately 25% of routine LT cases). 35 All of these exacerbate VQ mismatch through a mechanism distinct from that of HPS by primarily affecting ventilation rather than perfusion. This might also explain why inhaled vasodilators were only transiently effective when they were used in patient 2 (who had VAP and resulting diffuse alveolar damage) and when they were used for the second time in patient 4 (who had VAP).…”

Section: Discussionmentioning

confidence: 99%

Defining and characterizing severe hypoxemia after liver transplantation in hepatopulmonary syndrome

et al. 2013

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Hepatopulmonary syndrome is defined as a triad of liver disease, intrapulmonary vascular dilatations, and abnormal gas exchange, and it carries a poor prognosis. Liver transplantation is the only known cure for this syndrome. Severe hypoxemia in the early postoperative period has been reported to be a major complication and often leads to death in this population, but it has been poorly characterized. We sought to propose an objective definition for this complication and to describe its risk factors, incidence, and outcomes. We performed a systematic literature search and reviewed our single-center experience to characterize this complication. On the basis of the most commonly applied definition in 27 identified studies, we objectively defined severe postoperative hypoxemia as hypoxemia requiring a 100% fraction of inhaled oxygen to maintain a saturation 85% and out of proportion to any concurrent lung process. Nineteen of the 27 reports (70%) fulfilled this definition, as did 4 of the 21 patients (19%) at our center. We determined the prevalence and mortality of this complication from reports including 10 or more consecutive patients and providing sufficient postoperative details to determine whether this complication had occurred. In these reports, the prevalence of this complication was 12% (25/209). For the 11 cases with reported outcomes, the posttransplant mortality rate was 45% (5/11). There was a trend toward an increased risk of developing this complication in patients with very severe preoperative hypoxemia, defined as a partial pressure of arterial oxygen 50 mm Hg (8/41 with very severe hypoxemia versus 3/49 without severe hypoxemia, P 5 0.053), and there was a significantly increased risk for patients with anatomic shunting 20% (7/25 with anatomic shunting 20% versus 1/25 without anatomic shunting 20%, P 5 0.049). In conclusion, increased preoperative vigilance for this common complication is required among high-risk patients, and further research is required to identify the best management strategies.

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“…Due to the reasons mentioned above, we were rather surprised when we found that the incidence of VAP was similar in the transplanted and non-transplanted patients. Pellegrino et al also report that liver transplantation does not increase the incidence of VAP compared to other surgical patients 14 . Despite the fact that the two groups were comparable in sex, age, length of stay in ICU and mortality, the main diff erence was found to be SAPS II score on admission to the ICU.…”

Section: Discussionmentioning

confidence: 98%

Ventilator-Associated Pneumonia: Comparing Cadaveric Liver Transplant and Non-Transplant Surgical Patients

Brusich

2016

acc

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SUMMARY -Ventilator-associated pneumonia is a frequent complication in intensive care surgical patients, particularly those with high severity scores on admission. We studied the incidence and clinical outcome of ventilator-associated pneumonia among patients undergoing major general surgery procedures and those undergoing cadaveric liver transplantation in our hospital. Patients with the intensive care unit stay longer than four days having undergone surgery or transplantation and mechanically ventilated for more than 48 hours were included in the study. Ventilator-associated pneumonia diagnosis was based on a combination of radiological signs (progressive infi ltrate on chest radiograph), clinical signs (fever >38.3 °C, leukocytes >12×10 9 /mL) and microbiological data (positive culture from tracheal aspiration >10 5 or bronchoalveolar lavage >10 4 colonies/mL). Medical records of 1037 patients were reviewed and 157 patients were found to have been mechanically ventilated for more than 48 hours: 62 transplanted and 95 non-transplanted. Only 39 (24.84%) patients matched the criteria for ventilator-associated pneumonia. Th ere were no diff erences in sex, age, duration of mechanical ventilation, length of stay or outcome between the two groups. However, the main diff erence was the mean severity score on admission (Simplifi ed Acute Physiology Score II) which was higher among non-transplant patients (42±16 vs. 31±9; p=0.03). Gram-negative bacteria were the leading causative agents (82.03%) and were multidrug-resistant. In the intensive care surgical population, transplantation per se does not seem to increase patient risk for either ventilator-associated pneumonia acquisition or worse outcomes.

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Incidence and Clinical Outcomes of Ventilator-Associated Pneumonia in Liver Transplant and Non-Liver Transplant Surgical Patients

Cited by 13 publications

References 9 publications

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Early-onset pneumonia after liver transplantation: Microbiological findings and therapeutic consequences

Defining and characterizing severe hypoxemia after liver transplantation in hepatopulmonary syndrome

Ventilator-Associated Pneumonia: Comparing Cadaveric Liver Transplant and Non-Transplant Surgical Patients

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