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BACKGROUND Intraoperative cardiac arrest (ICA) has a reported frequency of 1 in 10,000 anesthetics but has a much higher estimated incidence in orthotopic liver transplantation (OLT). Single-center studies of ICA in OLT are limited by small sample size that prohibits multivariable regression analysis of risks. METHODS Utilizing data from 7 academic medical centers, we performed a retrospective, observational study of 5296 adult liver transplant recipients (18-80 years old) between 2000 and 2017 to identify the rate of ICA, associated risk factors, and outcomes. RESULTS ICA occurred in 196 cases (3.7% 95% confidence interval [CI], 3.2-4.2) and mortality occurred in 62 patients (1.2%). The intraoperative mortality rate was 31.6% in patients who experienced ICA. In a multivariable generalized linear mixed model, ICA was associated with body mass index (BMI)

Background Dyad learning has been shown to be an effective tool for teaching procedural skills, but little is known about how dyad learning may impact the stress, anxiety, and cognitive load that a student experiences when learning in this manner. In this pilot study, we investigate the relationship between dyad training on stress, anxiety, cognitive load, and performance in a simulated bradycardia scenario. Methods Forty-one fourth-year medical school trainees were randomized as dyads (n = 24) or individuals (n = 17) for an education session on day 1. Reassessment occurred on day 4 and was completed as individuals for all trainees. Primary outcomes were cognitive load (Paas scale), stress (Cognitive Appraisal Ratio), and anxiety levels (abbreviated State-Trait Anxiety Inventory). Secondary outcomes were time-based performance metrics. Results On day 1 we observed significant differences for change in anxiety and stress measured before and after the training scenario between groups. Individuals compared to dyads had larger mean increases in anxiety, (19.6 versus 7.6 on 80-point scale, p = 0.02) and stress ratio (1.8 versus 0.9, p = 0.045). On the day 4 post-intervention assessment, no significant differences were observed between groups. Secondary outcomes were significant for shorter time to diagnosis of bradycardia (p = 0.01) and time to initiation of pacing (p = 0.04) in the dyad group on day 1. On day 4, only time to recognizing the indication for pacing was significantly shorter for individual training (hazard ratio [HR] = 2.26, p = 0.02). Conclusions Dyad training results in lower stress and anxiety levels with similar performance compared to individual training.

Background We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. Methods A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant’s technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Results Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Conclusions Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

Introduction We developed a taxonomy of simulation delivery and documentation deviations noted during a multicenter, high-fidelity simulation trial that was conducted to assess practicing physicians' performance. Eight simulation centers sought to implement standardized scenarios over 2 years. Rules, guidelines, and detailed scenario scripts were established to facilitate reproducible scenario delivery; however, pilot trials revealed deviations from those rubrics. A taxonomy with hierarchically arranged terms that define a lack of standardization of simulation scenario delivery was then created to aid educators and researchers in assessing and describing their ability to reproducibly conduct simulations. Methods Thirty-six types of delivery or documentation deviations were identified from the scenario scripts and study rules. Using a Delphi technique and open card sorting, simulation experts formulated a taxonomy of high-fidelity simulation execution and documentation deviations. The taxonomy was iteratively refined and then tested by 2 investigators not involved with its development. Results The taxonomy has 2 main classes, simulation center deviation and participant deviation, which are further subdivided into as many as 6 subclasses. Inter-rater classification agreement using the taxonomy was 74% or greater for each of the 7 levels of its hierarchy. Cohen kappa calculations confirmed substantial agreement beyond that expected by chance. All deviations were classified within the taxonomy. Conclusions This is a useful taxonomy that standardizes terms for simulation delivery and documentation deviations, facilitates quality assurance in scenario delivery, and enables quantification of the impact of deviations upon simulation-based performance assessment.

Objective To investigate whether the addition of liposomal bupivacaine abdominal wall blocks to a multimodal analgesic regimen improves postoperative numeric rating scale pain scores and reduces opioid consumption in patients undergoing living liver donation. Patients and Methods We conducted a single-center, retrospective review of patients who underwent living liver donation from January 1, 2011, through February 19, 2016, and received multimodal analgesia with (block group) or without (control group) abdominal wall blockade. The block solution consisted of liposomal bupivacaine (266 mg) mixed with 30 mL of 0.25% bupivacaine. Both groups received intrathecal hydromorphone. Main outcome measures were pain scores, opioid requirements, time to full diet, and bowel activity. Results Postoperative day 0 pain scores were significantly better in the block group (n=29) than in the control group (n=48) (2.4 vs 3.5; P=.002) but were not significantly different on subsequent days. Opioid requirements were significantly decreased for the block group in the postanesthesia care unit (0 vs 9 mg oral morphine equivalents; P=.002) and on postoperative day 0 (7 vs 18 mg oral morphine equivalents; P=.004). Median (interquartile range) time to full diet was 23 hours (14-30 hours) in the block group and 38 hours (24-53 hours) in the control group (P=.001); time to bowel activity was also shorter in the block group (45 hours [38-73 hours] vs 67 hours [51-77 hours]; P=.01). Conclusion Abdominal wall blockade with liposomal bupivacaine after donor hepatectomy provides an effective method of postoperative pain control and decreases time to full diet and bowel activity.

To determine whether glove use modifies tactile and psychomotor performance of health care providers when compared with no glove use and to evaluate factors that influence the selection of sterile glove brand.Forty-two anesthesia providers (nine anesthesiologists, seven nurse anesthetists, 20 residents, six student nurse anesthetists) enrolled in and completed this cross-over randomized trial from May 2010 until August 2011. Participants underwent standardized psychomotor testing while wearing five different types of protective gloves. Assessments of psychomotor performance included tactile, fine motor/dexterity, and hand-eye coordination tests. Subjective ratings of glove comfort and performance were reported at the completion of each glove trial. The manufacturer's suggested retail price was collected for each glove tested.There were statistically significant differences in touch sensitivity for all nerve distributions, with all glove types resulting in less sensitivity than a bare hand. When compared with the non-sterile glove, only the thickest glove tested (Ansell Perry Orthopaedic) was found to have less touch sensitivity. Fine motor dexterity testing revealed no statistically significant differences in time to completion amongst glove types or bare handed performance. In hand-eye coordination testing across treatment conditions, the thickest glove tested (Ansell Perry(®) Orthopaedic) was the only glove to show a statistically significant difference from a bare hand. There were statistically significant differences in glove comfort ratings across glove types, with latex-free, powder-free (Cardinal Esteem(®)), and latex powder-free (Mölnlycke-Biogel(®)) rated highest; however, there were no statistically significant differences in subjective performance ratings across glove types.Given the observed similarities in touch sensitivity and psychomotor performance associated with five different glove types, our results suggest that subjective provider preferences, such as glove comfort, should be balanced against material costs.

Summary Background Patients undergoing total knee arthroplasty usually receive a multimodal analgesic regimen including peripheral nerve blockade, but may still experience significant pain. This study examined whether preoperative gabapentin decreases acute postoperative pain and opioid consumption in this setting. Methods Retrospective chart review of single institution, hospital-based orthopaedic practice. Consecutive patients undergoing unilateral elective primary knee arthroplasty were evaluated for perioperative gabapentin use. Sixty-one consecutive patients received gabapentin; for each, an age- and gender-matched control was identified. Results Patients in both groups demonstrated similar demographics, all received lumbar plexus blockade. Catheters were removed on postoperative day 2 (95%). There were no differences in postoperative pain scores or opioid use between groups. Overall, median verbal pain scores (IQR) were 0(1), 0(3), 1(3) and 3(3) in the post-anaesthesia care unit and postoperative days 0, 1 and 2, respectively. Postoperative consumption of other analgesics was not different across groups. Patients in the gabapentin group received a single-injection sciatic nerve block less often than patients in the control group (77% vs. 94%, respectively; p Conclusions Patients undergoing unilateral total knee arthroplasty experience low pain scores utilizing a multimodal analgesic regimen including continuous lumbar plexus blockade independent of gabapentin use.

A standard operating process for assessment, design, and follow-through of simulation-based education was developed to improve simulation experiences and optimize customer and staff satisfaction in a large multidisciplinary simulation center. Information is provided to describe development and implementation of a standard operating process for a large multidisciplinary simulation center. The Model for Improvement, a continuous improvement method, is the framework used to systematically describe the design, implementation, and monitoring of the standard operating process. A standard operating process is essential for success when high volumes and multiple disciplines are doing simulation-based education in a large simulation center. Utilization of a process for helping new and recurrent customers develop simulation-based education within a continuous improvement framework can increase both efficiency and the satisfaction of customers and simulation faculty and staff.

Simulation training is rapidly becoming an integral element of the education curriculum of anesthesia residency programs. We report a case of successful resuscitation of bupivacaine-induced cardiac arrest treated with i.v. lipid emulsion by providers who had recently participated in simulation training involving a scenario nearly identical to this case. Upon debriefing, it was determined that the previous training influenced execution of the following steps: rapid problem recognition, prompt initiation of specific therapy in the setting of supportive advanced cardiac life support measures, and coordinated team efforts. Although the true cause of efficient resuscitation and ultimate recovery cannot be proven, the efficiency of the resuscitation process, including timely administration of lipid emulsion, is evidence that simulation may be useful for training providers to manage rare emergencies.

The maternal mortality rate in the United States has stagnated for the past 2 decades. To further lower morbidity and mortality, we must take a broader perspective. When a pregnant woman is treated in a nonobstetric part of the hospital, care must adapt quickly to her special needs. Excessive concern as to medication, radiation, and litigation may render her care neither safe, timely, efficient, effective, nor patient-centered. Anesthesiologists can significantly improve the care of the pregnant patient by applying their uniquely broad-based skills, experience, and knowledge outside the labor unit.

To develop and evaluate a participant rating scale for assessing high performance teamwork skills in simulation medicine settings.In all, 107 participants in crisis resource management (CRM) training in a multidisciplinary medical simulation center generated 273 ratings of key CRM skills after participating in two or three simulation exercises. These data were analyzed using Rasch and traditional psychometric approaches to develop the 16-item Mayo High Performance Teamwork Scale (MHPTS). Sensitivity to change as a result CRM training was also evaluated.The MHPTS showed satisfactory internal consistency and construct validity by Rasch (person reliability = 0.77; person separation = 1.85; item reliability = 0.96; item separation = 5.04) and traditional psychometric (Cronbach's alpha = 0.85) indicators. The scale demonstrated sensitivity to change as a result of CRM training (pretraining mean = 21.44 versus first posttraining rating mean = 24.37; paired t = -4.15, P0.0001; first posttraining mean = 24.63 versus second posttraining mean = 26.83; paired t = -4.31 P0.0001).The MHPTS provides a brief, reliable, practical measure of CRM skills that can be used by participants in CRM training to reflect on and evaluate their performance as a team. Further evaluation of validity and appropriateness in other simulation and medical settings is desirable.

Aortic stenosis (AS) is a major risk factor for perioperative cardiac events in patients undergoing noncardiac surgery. We previously showed that selected patients with AS who were not candidates for, or refused, aortic valve replacement could undergo noncardiac surgery with acceptable risk. We extended our previous experience over a subsequent 5-year period by retrospectively analyzing the perioperative course of all patients with severe AS (aortic valve area index0.5 cm2/m2 or mean gradient50 mm Hg), determined with Doppler echocardiography or cardiac catheterization, who underwent noncardiac surgery. Nineteen patients underwent 28 surgical procedures: 22 elective and 6 emergency. The types of these procedures were 12 orthopedic, 6 intraabdominal, 4 vascular, 4 urologic, 1 otolaryngologic, and 1 thoracic. Mean age was 75 +/- 8 years. Of the 19 patients, 16 (84%) hador = 1 symptom: dyspnea, angina, syncope, or presyncope. Mean left ventricular ejection fraction was 61 +/- 11%. The type of anesthesia was general in 26 procedures and continuous spinal in 2. Intraarterial monitoring of blood pressure was used in 20 of the 28 surgical procedures. Intraoperative hypotensive events were treated promptly, primarily with phenylephrine. In all cases the anesthesia team was aware of the severity of the AS and integrated this into the anesthetic plan. Two patients (elective operation in 1 and emergency in 1) had complicated postoperative courses and died. There were no other intraoperative or postoperative events in any of the other patients. Although aortic valve replacement remains the primary treatment for patients with severe AS, selected patients with severe AS, who are otherwise not candidates for aortic valve replacement, can undergo noncardiac surgery with acceptable risk when appropriate intraoperative and postoperative management is used.

Objective: We describe BIS values for a patient undergoing breast surgery under self-hypnosis in order to access the value of global surface EEG measures occurring during this process. Methods: Following verbal consent, a BISTM monitor (Aspect Medical, Newton MA) was placed and values measured while the patient performed self-hypnosis for a simple mastectomy and sentinel node biopsy. Results: Thirty-nine minutes after incision the BIS value decreased transiently to 72 followed by several other transient decreases, the lowest of which was 59. Values remained at approximately 90 throughout most of the operative period. The BIS value returned to baseline after completion of the operation. Conclusions: Our findings support the hypothesis that hypnosis is a dynamic cerebral process incorporating many changes within brain activation centers and one distinct from dissociative patterns seen under anesthesia. Current algorithms employed by the BISTM monitor add little to the management of patients utilizing hypnosis for analgesia.

The specialty of anesthesiology has been at the forefront of healthcare simulation from its development and early applications to pioneering simulation for residency training requirements and maintenance of specialty board status. As such, the specialty of anesthesiology has a rich and mature experience with simulation. In this chapter we will explore the application of simulation to the field of anesthesiology with regard to training, assessment, and maintenance of competence. Given the specialty’s extensive experience, much of the chapter will be devoted to the “art” of simulation with a detailed discussion of scenario, course, and curricular development.

Introduction. Indirect video laryngoscopes are altering the landscape of airway management. The primary aim of this prospec-tive randomized patient simulator analysis was to objectively compare video laryngoscopes to standard airway management techniques in novice users.Methods. "First year medical students were exposed to high-fidelity simulated normal and difficult airway scenarios while using an array of indirect video laryngoscopes (e.g., the GlideScope, McGRATH or Pentax AWS-100) that were compared to Macin-tosh laryngoscope and fiberoptic bronchoscope (i.e., historic gold standards for normal and difficult airways, respectively)." Results. In the normal airway scenario, the best glottic view (both subjective and objective) was obtained with the video laryngoscopes and intubation success rates were highest with the video laryngoscopes (100% success rate for each device) and Macintosh (80%). In the difficult airway scenario, the best glottic view was achieved with all video laryngoscopes and the fiberoptic bronchoscope; however, tracheal intubation was best achieved with the video laryngoscopes (100% success rate for each device) whereas the success rate with the bronchoscope was only 36%.Discussion. Our findings support the use of the GlideScope, McGRATH, or Macintosh laryngoscopes for novice users mana-ging a normal airway. When managing the difficult airway, there was no difference between any video or Macintosh laryngosco-pe in the time to successfully intubate the trachea. Over time, study participants demonstrated learned behavior as they became more facile with all devices. When comparing the video laryngoscopes, all three performed similarly overall and proved useful in the hands of novice users. Regardless of airway difficulty, the fiberoptic bronchoscope yielded the worst results.

The transition from medical student to intern is inherently stressful, with potentially negative consequences for both interns and patients.We describe Internship Boot Camp, an innovative course specifically designed to prepare fourth-year medical students for the transition from medical school to internship. An intensive 1-week course, Internship Boot Camp has simulated, longitudinal patient-care scenarios that use high-fidelity medical simulation, standardized patients, procedural task trainers, and problem-based learning to help students apply their knowledge and develop a framework for response to the challenges they will face as interns.In March 2007, 12 students participated in the course as an elective in their final year of medical school, and the other 28 students in their class did not. After beginning internship and 5 to 7 months after the completion of Internship Boot Camp, all 40 former students were asked to complete a blinded survey about their preparation for internship. The overall response rate for the survey was 80%. Of responders to an open-ended question about the aspects of medical school training that best prepared them for internship, 89% (8 of 9) of course participants listed "Internship Boot Camp." The next highest response ("subinternship") was given by 45% (9 of 20) of nonparticipants and 33% (3 of 9) of course participants.Internship Boot Camp is a unique learning environment that is recalled by participants as the most helpful, of all components of their medical school education, in preparation for internship.

Background and Objectives: The use of ultrasound technology for vascular access and regional anesthesia is gaining widespread acceptance among anesthesia providers. As a result, many group practices and medical institutions are considering purchasing ultrasound equipment. Currently, comparative information regarding the ergonomic design, physical and adjustable features, data management, ease of use, cost, and image quality of various ultrasound machines is not available. The primary goal of this investigation was to develop an objective process of evaluating ultrasound equipment before purchase. The process of evaluation used in the current investigation may be used when comparing a variety of medical technologies. Methods: A randomized, side-by-side comparative evaluation of 7 different ultrasound machine models was performed. Sixteen resident physicians without prior ultrasound experience (inexperienced providers) completed a formal evaluation of each machine model after performing a standardized machine configuration and performance checklist. Inexperienced providers and 10 faculty members experienced in ultrasound-guided regional anesthesia evaluated the image quality of 2 standardized images acquired from each machine model. Results: Overall, evaluators rated questions on the machine evaluation form as "very good" or "outstanding" 70% or more of the time for all machine models. The largest, most complex ultrasound machine was rated as having the best image quality by both inexperienced and experienced providers. Ultrasound machine models with the simplest ergonomic design and user interface were rated highest by inexperienced study participants. Conclusions: Anesthesia providers considering an ultrasound equipment purchase should objectively evaluate machine models that have features most important to their own clinical practice. Ergonomic design, physical and adjustable features, data management, ease of use, image quality, and cost are important features to consider when evaluating an ultrasound machine.

Education experts have suggested that many doctors know what to teach, but few know how to teach.1 This statement stems from the fact that most physicians do not receive formal instruction in education theory or methodology during their own medical training. As a result, apprenticeship models of education have prevailed as the primary mode of teaching regional anesthesia to residents in-training for the past several decades. Limitations to this style of teaching include inconsistent learning experiences and limited case numbers. Recently, Richman et al2 demonstrated that a dedicated regional anesthesia rotation may increase the number of blocks performed by residents by concentrating their learning experiences into a focused period. Although this approach represents an educational step forward, most regional anesthesia curricula continue to revolve around an apprenticeship style of training. The Accreditation Council for Graduate Medical Education (ACGME) has also made attempts to improve resident education by implementing standardized education performance objectives (ie, competencies) and establishing minimum regional block numbers for anesthesia residents during the past decade (for complete explanation of ACGME competencies, see http://www.acgme.org/acWebsite/ home/home.asp). However, it has been estimated that 40% of residents lack adequate exposure or proficiency in peripheral nerve blockade. Finally, the introduction of ultrasound-guided regional anesthesia (UGRA) and the national spotlight on patient safety and quality care initiatives have introduced new challenges for regional anesthesia educators. In an effort to address these and many other concerns, we recently redesigned and implemented a new regional anesthesia curriculum within our institution. This curriculumVwhich describes a single institution’s approach to resident educationVis reviewed within this special article.

It is a simplification to view simulators as the solution that will address shortcomings in education. Simulation is not the end point; it is only a tool that must be one part of a well-considered and well-executed curriculum. This chapter will discuss some of the forces that are shaping how simulation is currently being used and will speculate on how they may impact the ways in which simulation may be used in the future, both in education and in the clinical setting. Recent technologic advances and how they may impact the use of simulation will be addressed. Practice, Policy, and Pressures Many changes have occurred in the medical educational environment in recent years. In response to increased awareness of the errors in medicine, the public has become skeptical of the healthcare system, which has led to growing demands for accountability, safe care, quality care, and demonstration of competency by the individuals and facilities that provide care. Patients are more vocal than ever about their care and are increasingly reluctant to participate in clinical education so that physicians in training can learn their craft, particularly if the physicians are junior learners. In addition, payers are demanding that clinicians produce evidence that they are improving the quality of care that they deliver. These factors frequently collide with the needs of learners in a clinical environment; as mentors carry heavier clinical loads in the face of lower reimbursements, patients become reluctant to have learners involved with their care, and their threshold for acceptance of errors becomes ever lower.

BACKGROUND: Although few studies have been performed recently, several have suggested that some practitioners are not well able to detect preset anesthesia machine faults. METHODS: We performed a prospective study to determine whether there is a correlation between duration of anesthesia practice and the ability to detect anesthesia machine faults. Our hypothesis was that more anesthesia practice would increase the ability to detect anesthesia machine faults. This study was performed during a nationally attended anesthesia meeting held at a large academic medical center, where 87 anesthesia providers were observed performing anesthesia machine checkouts. The participants were asked to individually check out an anesthesia machine with an unspecified number of preset faults. The primary outcome measures were the written listing of faults detected during an anesthesia machine checkout. RESULTS: Of the five faults preset into the test machine, participants with 0-2 yr experience detected a mean of 3.7 faults, participants with 2-7 yr experience detected a mean of 3.6 faults, and participants with more than 7 yr experience detected a mean of 2.3 faults (P < 0.001). CONCLUSIONS: Our prospective study demonstrated that anesthesia machine checkout continues to be a problem.

The training of physician learners in intensive care and coronary care medicine presents several unique challenges that are particularly suited to simulation-based medical education (SBME) solutions. Intensive care medical educators seek to provide evidence-based medical education and comprehensive clinical exposure for learners in the setting of maximal individual patient comfort and safety. This represents both a practical and ethical dilemma for educators - one that SBME can partially solve in a way that provides significant advantages over conventional "bedside" training, particularly in the intensive care setting among critically ill patients.

Non-focal postoperative mental status changes can be challenging. Single patient case report and medical literature review. We describe a 67-year-old male who was admitted for radical cystectomy and ileal conduiturinary diversion. General anesthesia was uneventful and the patient remained hemodynamically stable throughout the procedure. At the end of the procedure, the patient's tracheal was extubated. Initially, he was arousable, able to move all extremities, and answer questions appropriately. Over the next 2 hours, his mental status waxed and waned and respirations became irregular. An emergent head computed tomogram without contrast revealed a hyperdense basilar artery consistent with acute thrombosis. Vascular radiology intervention occurred approximately 9 hours after the onset of symptoms, but there was no improvement in the patient's neurological status and the subsequently died. Although nonfocal postoperative mental status changes are common and often secondary to benign etiologies, they may herald more significant pathology, including stroke. Patients with postoperative mental status changes should be evaluated carefully to identify like-threatening and treatable etiologies. Recent advance in the acute care of stroke such as thrombolysis and angioplasty, can improve outcome if instituted promptly.

Patients with end-stage liver disease usually show a hyperdynamic circulatory state. It has previously been reported that patients who develop myocardial depression in the early post–liver transplantation period are more prone to organ failure and death. We reviewed the records of 754 adult patients undergoing liver transplantation at our institution and identified 7 patients who initially showed hyperdynamic circulation, but then developed reversible dilated cardiomyopathy in the early posttransplantation period. All identifiable causes of cardiac dysfunction, such as myocardial ischemia, thyroid dysfunction, and electrolyte imbalances, were excluded. Left ventricular ejection fraction decreased from a preoperative median baseline of 60% to 20% (P = .02), with four-chamber dilatation on echocardiogram. All these patients required supportive care, including mechanical ventilation, afterload reduction, inotropic support, and monitoring in the intensive care unit. Cardiac function subsequently improved in all patients, with ejection fraction increasing to a median of 50%. All patients were discharged from the hospital. At a median follow-up of 15 months, there was no recurrence of heart failure. The increased peripheral resistance seen after successful liver transplantation may be an important causative factor.