title: Association of intraoperative blood pressure instability with adverse outcomes after liver transplantation.
abstract: BACKGROUND
  Blood pressure derangements are common in orthotopic liver transplantation (OLT), and are potentially associated with adverse outcomes if they are sustained. While this concept is often believed to be true, few have rigorously demonstrated the validity of this claim, especially in likely vulnerable OLT patients.
  
  
  METHODS
  We retrospectively investigated 827 patients who underwent OLT to determine the magnitude of these hemodynamic associations with adverse outcomes. The median value of the mean arterial pressure (MAP) and the fractional change in the median MAP between subsequent epochs (FCM) were calculated for every 5-minute epoch intraoperatively. Epochs were classified according to prespecified ranges of MAP and fractional changes in MAP (lability) between epochs. Multivariate stepwise logistic regression was used to model associations of risk factors and epochs of intraoperative blood pressure (BP) instability with primary (30-day mortality and/or graft failure) and secondary adverse outcomes.
  
  
  RESULTS
  Primary adverse outcomes occurred in 10.9% and 12.2% of patients for 30-day mortality and 30-day graft failure, respectively. Independent hemodynamic predictors for 30-day mortality and graft failure included sustained periods of MAP <50 mmHg and BP lability where the MAP changed >25%. All of these values were statistically significant.
  
  
  CONCLUSIONS
  Although severe intraoperative hypotension and BP lability during OLT are often observed in current practice as consequences of major surgical manipulations and patient vulnerability, these are likely not benign conditions based on this retrospective analysis. Prospective trials are warranted to investigate the possibility that interventions tailored to avoidance of hypotension and BP lability may improve outcomes.
authors.affiliation: Department of Anesthesiology, The Mount Sinai Medical Center, New York, NY 10029, USA. samuel.demaria@mountsinai.org.
authors.forename: S
authors.initials: S
authors.lastname: De Maria
authors.forename: J
authors.initials: J
authors.lastname: Nürnberg
authors.forename: H M
authors.initials: HM
authors.lastname: Lin
authors.forename: A G
authors.initials: AG
authors.lastname: Contreras-Saldivar
authors.forename: M
authors.initials: M
authors.lastname: Levin
authors.forename: K
authors.initials: K
authors.lastname: Flax
authors.forename: D
authors.initials: D
authors.lastname: Groth
authors.forename: J
authors.initials: J
authors.lastname: Vullo
authors.forename: J
authors.initials: J
authors.lastname: Rocca
authors.forename: S
authors.initials: S
authors.lastname: Florman
authors.forename: D L
authors.initials: DL
authors.lastname: Reich
mesh_terms: D000328:Adult; D000368:Aged; D001794:Blood Pressure / Q000502:physiology*; D015331:Cohort Studies; D005260:Female; D006085:Graft Survival; D006801:Humans; D006973:Hypertension / Q000503:physiopathology; D007022:Hypotension / Q000503:physiopathology; D007432:Intraoperative Period; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D012307:Risk Factors; D017211:Treatment Failure; D016896:Treatment Outcome