Death after portal decompressive surgery. Physiologic state, metabolic adequacy, and the sequence of development of the physiologic determinants of survival.

Detailed serial cardiovascular and respiratory physiologic studies were carried out in 80 patients with cirrhotic liver disease, including 45 cirrhotic patients who underwent portal decompressive surgery on an urgent or elective basis. In surgical cases, death could be predicted from the first postoperative day's pattern of response. Predictors of death were an increase in percent of pulmonary shunt due to a redistribution of the increased pulmonary blood flow, and a disproportionate fall in vascular tone, which permits an increased cardiac ejection fraction even when significant myocardial depression occurs. The etiology of the vascular tone defect seems related to the rise in levels of the false neurotransmitter octopamine, which are shown to increase as oxygen consumption falls in the patho-physiologic hyperdynamic B state, presumably due to a block in the oxidative metabolism of aromatic amino acids.