title: Increased Intraoperative Fluid Administration Is Associated with Severe Primary Graft Dysfunction After Lung Transplantation.
abstract: BACKGROUND
  Severe primary graft dysfunction (PGD) is a major cause of early morbidity and mortality in patients after lung transplantation. The etiology and pathophysiology of PGD is not fully characterized and whether intraoperative fluid administration increases the risk for PGD remains unclear from previous studies. Therefore, we tested the hypothesis that increased total intraoperative fluid volume during lung transplantation is associated with the development of grade-3 PGD.
  
  
  METHODS
  This retrospective cohort analysis included patients who had lung transplantation at the Cleveland Clinic between January 2009 and June 2013. We used multivariable logistic regression with adjustment for donor, recipient, and perioperative confounding factors to examine the association between total intraoperative fluid administration and development of grade-3 PGD in the initial 72 postoperative hours. Secondary outcomes included time to initial extubation and intensive care unit length of stay.
  
  
  RESULTS
  Grade-3 PGD occurred in 123 of 494 patients (25%) who had lung transplantation. Patients with grade-3 PGD received a larger volume of intraoperative fluid (median 5.0 [3.8, 7.5] L) than those without grade-3 PGD (3.9 [2.8, 5.2] L). Each intraoperative liter of fluid increased the odds of grade-3 PGD by approximately 22% (adjusted odds ratio, 1.22; 95% confidence interval [CI], 1.12-1.34; P <0.001). The volume of transfused red blood cell concentrate was associated with grade-3 PGD (1.1 [0.0, 1.8] L for PGD-3 vs 0.4 [0.0, 1.1 for nongrade-3 PGD] L; adjusted odds ratio, 1.7; 95% CI, 1.08-2.7; P = 0.002). Increased fluid administration was associated with longer intensive care unit stay (adjusted hazard ratio, 0.92; 97.5% CI, 0.88-0.97; P < 0.001) but not with time to initial tracheal extubation (hazard ratio, 0.97; 97.5% CI, 0.93-1.02; P = 0.17).
  
  
  CONCLUSIONS
  Increased intraoperative fluid volume is associated with the most severe form of PGD after lung transplant surgery. Limiting fluid administration may reduce the risk for development of grade-3 PGD and thus improve early postoperative morbidity and mortality after lung transplantation.
authors.affiliation: From the *Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio; †Department of Anesthesiology and Critical Care, Cleveland Clinic, Cleveland, Ohio; ‡Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio; §Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; ‖Transplantation Center, Department of Pulmonology, Allergy and Critical Care, Cleveland Clinic, Cleveland, Ohio; ¶Departments of Outcomes Research and General Anesthesiology, Cleveland Clinic, Cleveland, Ohio; #Transplantation Center, Department of Thoracic and Cardiovascular Surgery and Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio; and **Departments of Cardiothoracic Anesthesia and Outcomes Research, Cleveland Clinic, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Mariya A
authors.initials: MA
authors.lastname: Geube
authors.forename: Silvia E
authors.initials: SE
authors.lastname: Perez-Protto
authors.forename: Tory L
authors.initials: TL
authors.lastname: McGrath
authors.forename: Dongsheng
authors.initials: D
authors.lastname: Yang
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.forename: Marie M
authors.initials: MM
authors.lastname: Budev
authors.forename: Andrea
authors.initials: A
authors.lastname: Kurz
authors.forename: Kenneth R
authors.initials: KR
authors.lastname: McCurry
authors.forename: Andra E
authors.initials: AE
authors.lastname: Duncan
mesh_terms: D000328:Adult; D015331:Cohort Studies; D005260:Female; D005440:Fluid Therapy / Q000009:adverse effects*; D006801:Humans; D007430:Intraoperative Care / Q000009:adverse effects*; D016040:Lung Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000139:chemically induced / Q000175:diagnosis; D055031:Primary Graft Dysfunction / Q000139:chemically induced* / Q000175:diagnosis*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D055815:Young Adult