title: Intraoperative epoprostenol and nitric oxide for severe pulmonary hypertension during orthotopic liver transplantation: a case report and review of the literature.
abstract: BACKGROUND
  The presence of pulmonary hypertension in patients scheduled for liver transplantation requires a comprehensive perioperative heart evaluation and treatment with epoprostenol (prostacycline) infusion until a liver donor becomes available. We contended that intraoperative attenuation of severe pulmonary hypertension could be achieved by epoprostenol infusion combined with nitric oxide inhalation.
  
  
  METHODS
  A 49 years old man with end stage liver disease secondary to hepatitis C and ethanol abuse presented for orthotopic liver transplantation. The case was complicated by severe pulmonary hypertension. Preoperative epoprostenol, at doses ranging from 6 to 26 ng.kg(-1).min(-1), was infused during the induction of anesthesia. Although lower than before (>70 mmHg), post-induction pulmonary pressure (by Swan-Ganz catheter) was 62/30 mmHg. Prior to surgical incision nitric oxide (NO) by inhalation was commenced, increasing the concentration from 10 to 40 ppm; pulmonary artery pressure (PAP) then declined to 55/25 mmHg. Before starting reperfusion of the transplanted liver, NO concentration was increased to 80 ppm: this allowed completion of the procedure with PAP at 32/16 mmHg. Real time transesophageal echocardiography indicated improvement in right heart function due to NO. Following surgery, NO was continued for 10 hs at a concentration of 40 ppm and the patient was then extubated. Epoprostenol infusion was continued for 2 months after the patient was discharged home; last PAP was measured 32/10 mmHg.
  
  
  CONCLUSIONS
  Severe intraoperative pulmonary hypertension during liver transplantation was successfully treated using the combination of IV epoprostenol infusion and NO inhalation in medium and high concentrations.
authors.affiliation: Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA, USA.
authors.forename: Youri
authors.initials: Y
authors.lastname: Vater
authors.forename: Kenneth
authors.initials: K
authors.lastname: Martay
authors.forename: Greg
authors.initials: G
authors.lastname: Dembo
authors.forename: T Andrew
authors.initials: TA
authors.lastname: Bowdle
authors.forename: Avi A
authors.initials: AA
authors.lastname: Weinbroum
mesh_terms: D000280:Administration, Inhalation; D011464:Epoprostenol / Q000008:administration & dosage*; D006801:Humans; D006976:Hypertension, Pulmonary / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D007262:Infusions, Intravenous; D007432:Intraoperative Period; D017093:Liver Failure / Q000150:complications / Q000601:surgery; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009569:Nitric Oxide / Q000008:administration & dosage*
chemical_list: D009569:Nitric Oxide; D011464:Epoprostenol