Norepinephrine Boluses for Post Reperfusion Syndrome in Living Donor Liver Transplantation

Abstract

Abstract Background: Post-reperfusion syndrome (PRS) is a serious hemodynamic event during liver transplantation, which increases early graft dysfunction and mortality. Many vasoactive drugs have been used, but norepinephrine boluses are new during PRS. Our study aimed to test the efficacy and safety of Norepinephrine boluses to prevent PRS during orthotopic liver transplantation. Methods: This feasibility phase II trial included 40 patients undergoing living donor liver transplantation. The intervention was an escalated protocol of higher than usual Norepinephrine boluses. The primary outcome was the incidence of PRS. The main secondary outcomes were arrhythmia, ECG ischemic changes, mean pulmonary pressure, 3-month survival, and one-year survival. Results: PRS occurred in 28 (70%) cases, (95% CI 54% to 83%, P-value < 0.001), with a relative risk reduction of 0.22 when compared to our previous results (90%). Twelve cases (30%) developed transient ECG ischemic changes (95% CI, 17% to 47%). All ECG ischemic changes returned to the baseline after correction of hypotension. There was no significant arrhythmia or bradycardia (95% CI 0 to 9%). The mean pulmonary artery pressure was not significantly higher than the normal limit, 20 mmHg. The 3-month survival was 95% (95% CI 83% to 99%), and the one-year survival was 93% (95% CI 80% to 98%). Conclusions: Our results suggest that escalating Norepinephrine boluses starting at 20 mcg is feasible and effective in reducing the risk of PRS during living donor liver transplantation. Additionally, Norepinephrine boluses were not associated with significant myocardial ischemic events, arrhythmia, or a rise in pulmonary pressure.