Abstract:

Objective Liver transplantation is an effective treatment for end-stage liver disease. However，early postoperative acute hypoxemic respiratory failure （AHRF） is one of the most critical medical complications，impeding rapid recovery. The etiology of post-liver transplantation AHRF is diverse， and the correlation betweenperioperative fluid management strategies and AHRF remains unreported in the literature. Whether specific fluid management strategies benefit AHRF patients is still unclear. This study aims to evaluate the impact of postoperative fluid management on AHRF and to analyze whether pulse index continuous cardiac output （PiCCO）-guided fluid therapy confers benefits， thereby optimizing clinical protocols. Methods Clinical data from 81 liver transplant recipients admitted to the Department of Critical Care Medicine， Renji Hospital， Shanghai Jiao Tong University School of Medicine， between December 2024 and April 2025 were retrospectively analyzed. Preoperative indicators （age，transplant type， electrocardiogram， cardiac ultrasound）， intraoperative blood loss， fluid infusion volume， peak lactatelevels， and postoperative PiCCO-based hemodynamic parameters were collected. The time to AHRF onset， etiology（infectious/non-infectious）， ICU stay， hospitalization duration， and their impacts on graft function and survival rates were evaluated. Results The incidence of postoperative AHRF was 22.2% （18/81）， with a median onset time of 3 days posttransplant. Among AHRF patients，72.2% （13/18） had non-infectious causes， and 27.8% （5/18） had infectious causes.AHRF occurrence showed no correlation with preoperative electrocardiogram or cardiac ultrasound findings， intraoperative blood loss， vasoactive drug use， peak lactate levels， postoperative portal vein velocity， hepatic artery velocity， or hepatic artery resistance index. Compared to non-AHRF patients， the AHRF group achieved comparable mean arterial pressure targets but exhibited a significantly higher fluid positive balance on postoperative day 1， elevated volume preload indicators， and increased extravascular lung water （EVLW） on days 1 and 2. The occurrence of AHRF prolonged ICU stays and total hospitalization duration. Conclusion Early postoperative AHRF in liver transplant recipients is associated with higher volume load and increased EVLW. PiCCO-guided monitoring of preload volume parameters 〔e.g.， global end-diastolic volume（GEDV）〕 facilitates optimal fluid management. Targeting GEDV at the lower limit of the normal range may represent a rational fluid management strategy. 

Key words:

Liver transplantation； , Acute hypoxemic respiratory failure； , Acute respiratory distress syndrome； , Fluid Management

摘要：

目的 肝移植是终末期肝病患者的有效治疗手段，但术后早期急性低氧性呼吸衰竭（acutehypoxemic respiratory failure， AHRF）是目前最主要的内科并发症之一，影响肝移植患者的快速恢复。肝移植术后 AHRF 的病因多样，肝移植术后液体管理策略与 AHRF 的相关性尚无文献报导，具体的液体管理策略对AHRF 患者是否获益仍不明，本研究旨在总结肝移植术后液体管理对 AHRF 的影响，分析脉搏指示连续心输出量监测（pulse index continuous cardiac output， PiCCO）指导液体治疗策略对 AHRF 是否获益，为优化管理策略提供依据。方法回顾性分析 2024 年 12 月至 2025 年 4 月上海交通大学医学院附属仁济重症医学科 81 例肝移植受者的临床资料。收集术前指标（年龄、移植方式、心电图、心脏超声）、术中失血量、输液量、乳酸 最高水平，术后基于 PICCO 的血流动力学参数及术后 AHRF 发生时间、病因（感染性 / 非感染性）、重症监护病房（intensive care unit， ICU）时间及住院天数，并评估其对移植物功能及生存率的影响。结果 术后 AHRF发生率为 22.2% （18/81），中位发生时间为术后 3 d。在发生 AHRF 的患者中，72.2% （13/18）的病因为非感染性，27.8% （5/18）为感染性。ARHF 发生与术前心电图、心超结果、术中失血量、是否使用血管活性药物、最高乳酸值，术后门静脉流速、肝动脉流速、肝动脉阻力指数无关。与未发生 AHRF 的患者相比，AHRF 组患者平均动脉压达标率一致，但术后第 1 天液体正平衡更多，术后第 1 天及第 2 天的容量前负荷指标及血管外肺水更高，发生 AHRF 的患者显著延长了 ICU 及总住院时间。结论 肝移植术后早期 AHRF 患者存在更高的容量负荷及更高的血管外肺水，基于 PICCO 监测前负荷容量指标有助于指导肝移植术后早期液体管理，控制全心舒张末期容积处于正常下限可能是合理的液体管理目标。

关键词: 肝移植 , 急性低氧性呼吸衰竭 , 急性呼吸窘迫综合征 , 液体管理