Postreperfusion syndrome

Following the anhepatic phase of liver transplant, the graft is reperfused. The postreperfusion syndrome is a syndrome of severe hemodynamic compromise, arrhythmia, or asystole that occurs immediately after reperfusion.

Definition: A decrease in systemic mean BP > 30% below baseline for at least 1 minute during the first 5 minutes of liver reperfusion.

The estimated incidence is 10-60% or higher of liver transplants with independent predictors including prolonged cold ischemia time and LV diastolic dysfunction1.

Proposed causes of postreperfusion syndrome include products of metabolism from the ischemic liver graft including vasoactive substances such as interleukin 6, tumor necrosis factor α, potassium and hydrogen ions, and possibly emboli which are released into the recipient’s bloodstream and distributed systemically. Additionally, various graft-preservation solutions, such as University of Wisconsin solution, contain a high potassium content and cause significant electrolyte disturbances during reperfusion.

The occurrence of postreperfusion syndrome correlates with post-operative renal dysfunction as well as higher intraoperative and postoperative mortality2. Management of postreperfusion syndrome includes close communication with the surgical team regarding the timing of reperfusion, pretreatment of the patient with the antihistamines (ranitidine and diphenhydramine) in the 15 minutes prior to reperfusion, and close hemodynamic monitoring at the time of graft outflow unclamping. Hypotension is treated with volume resuscitation and vasopressor agents, including infusion of phenylephrine, norepinephrine, vasopressin, and epinephrine. Methylene blue in cases refractory to vasoressors may also be considered, although prophylactic dosing has shown mixed results1. Treatment of electrolyte abnormalities (hypocalcemia, hyperkalemia, etc) is also necessary.


1. Valentine et al. Clinical Update in Liver Transplantation. Journal of Cardiothoracic and vascular anesthesia. 2013. Vol 27;4: 809-815.

2. Xu ZD, Xu HT, Yuan HB, et al. Postreperfusion syndrome during orthotopic liver transplantation: A single-center experience. Hepatobiliary Pancreat Dis Int. 2012;11:34-3


Elizabeth Valentine, Madeline Gregorits, Jacob T Gutsche, Lourdes Al-Ghofaily, John G T Augoustides
Clinical update in liver transplantation.
J. Cardiothorac. Vasc. Anesth.: 2013, 27(4);809-15
[PubMed:23849528] [] [DOI] (I p)

Zhen-Dong Xu, Hai-Tao Xu, Hong-Bin Yuan, Hao Zhang, Rui-Hua Ji, Zui Zou, Zhi-Ren Fu, Xue-Yin Shi
Postreperfusion syndrome during orthotopic liver transplantation: a single-center experience.
HBPD INT: 2012, 11(1);34-9
[PubMed:22251468] [] (I p)