Anesthetic Risk Factors Associated With Early Mortality in Pediatric Liver Transplantation

Development and validation of a multivariable prediction model in pediatric liver transplant patients for predicting intensive care unit length of stay

BACKGROUND

Liver transplantation is the life-saving treatment for many end-stage pediatric liver diseases. The perioperative course, including surgical and anesthetic factors, have an important influence on the trajectory of this high-risk population. Given the complexity and variability of the immediate postoperative course, there would be utility in identifying risk factors that allow prediction of adverse outcomes and intensive care unit trajectories.

AIMS

The aim of this study was to develop and validate a risk prediction model of prolonged intensive care unit length of stay in the pediatric liver transplant population.

METHODS

This is a retrospective analysis of consecutive pediatric isolated liver transplant recipients at a single institution between April 1, 2013 and April 30, 2020. All patients under the age of 18 years receiving a liver transplant were included in the study (n = 186). The primary outcome was intensive care unit length of stay greater than 7 days.

RESULTS

Recipient and donor characteristics were used to develop a multivariable logistic regression model. A total of 186 patients were included in the study. Using multivariable logistic regression, we found that age < 12 months (odds ratio 4.02, 95% confidence interval 1.20-13.51, p = .024), metabolic or cholestatic disease (odds ratio 2.66, 95% confidence interval 1.01-7.07, p = .049), 30-day pretransplant hospital admission (odds ratio 8.59, 95% confidence interval 2.27-32.54, p = .002), intraoperative red blood cells transfusion >40 mL/kg (odds ratio 3.32, 95% confidence interval 1.12-9.81, p = .030), posttransplant return to the operating room (odds ratio 11.45, 95% confidence interval 3.04-43.16, p = .004), and major postoperative respiratory event (odds ratio 32.14, 95% confidence interval 3.00-343.90, p < .001) were associated with prolonged intensive care unit length of stay. The model demonstrates a good discriminative ability with an area under the receiver operative curve of 0.888 (95% confidence interval, 0.824-0.951).

CONCLUSIONS

We develop and validate a model to predict prolonged intensive care unit length of stay in pediatric liver transplant patients using risk factors from all phases of the perioperative period.

Outcomes of Pediatric Liver Transplantation in Korea Using Two National Registries

BACKGROUND

This retrospective study aimed to evaluate overall survival and the risk factors for mortality among Korean pediatric liver transplantation (LT) patients using data from two national registries: the Korean Network Organ Sharing (KONOS) of the Korea Centers for Disease Control and Prevention and the Korean Organ Transplantation Registry (KOTRY).

METHODS

Prospectively collected data of 755 pediatric patients who underwent primary LT (KONOS, February 2000 to December 2015; KOTRY, May 2014 to December 2017) were retrospectively reviewed.

RESULTS

The 1-, 5-, 10-, and 15-year survival rates were 90.6%, 86.7%, 85.8%, and 85.5%, respectively, in KONOS, and the 1-month, 3-month, 1-year, and 2-year survival rates were 92.1%, 89.4%, 89.4%, and 87.2%, respectively, in KOTRY. There was no significant difference in survival between the two registries. Multivariate analysis identified that body weight ≥6 kg (p <0.001), biliary atresia as underlying liver disease (p = 0.001), and high-volume center (p < 0.001) were associated with better survival according to the KONOS database, while hepatic artery complication (p < 0.001) was associated with poorer overall survival rates according to the KOTRY database.

CONCLUSION

Long-term pediatric patient survival after LT was satisfactory in this Korean national registry analysis. However, children with risk factors for poor outcomes should be carefully managed after LT.

Pediatric liver transplantation: a North American perspective

Liver transplantation (LT) is an important component in the therapeutic armamentarium of managing end-stage liver disease. In North American children, biliary atresia remains the most common indication for LT compared to hepatitis C in adults, while hepatoblastoma is the most common liver tumor requiring LT, versus Hepatocellular carcinoma in adults. Rejection, lymphoproliferative disease, renal insufficiency, metabolic syndrome, recurrent disease, 'de novo' autoimmune hepatitis and malignancy require careful surveillance and prompt action in adults and children after LT. In children, specific attention to EBV viremia, growth, development, adherence and transition to the adult services is also required. Antibody mediated rejection and screening for donor specific antibodies is becoming important in managing liver graft dysfunction. Biomarkers to identify and predict tolerance are being developed. Machine perfusion and stem cells (iPS) to synthesize organs are generating interest and are a focus for research.

Adverse events related to gastrointestinal endoscopic procedures in pediatric patients under anesthesia care and a predictive risk model (AEGEP Study)

BACKGROUND

Multiple studies have analyzed perioperative factors related to adverse events (AEs) in children who require gastrointestinal endoscopic procedures (GEP) in settings where deep sedation is the preferred anesthetic technique over general anesthesia (GA) but not for the opposite case.

METHODS

We reviewed our anesthesia institutional database, seeking children less than 12 years who underwent GEP over a 5-year period. A logistic regression was used to determine significant associations between preoperative conditions, characteristics of the procedure, airway management, anesthetic approaches and the presence of serious and non-serious AEs.

RESULTS

GA was preferred over deep sedation [77.8% vs. 22.2% in 2178 GEP under anesthesia care (n=1742)]. We found 96 AEs reported in 77 patients, including hypoxemia (1.82%), bronchospasm (1.14%) and laryngospasm (0.91%) as the most frequent. There were 2 cases of severe bradycardia related to laryngospasm/hypoxemia and a case of aspiration resulting in unplanned hospitalization, but there were no cases of intra- or postoperative deaths. Final predictive model for perioperative AEs included age <1 year, upper respiratory tract infections (URTI) <1 week prior to the procedure and low weight for the age (LWA) as independent risk factors and ventilation by facial mask as a protector against these events (p<0.05).

CONCLUSIONS

AEs are infrequent and severe ones are remote in a setting where AG is preferred over deep sedation. Ventilatory AEs are the most frequent and depend on biometrical and comorbid conditions more than anesthetic drugs chosen. Age <1 year, history of URTI in the week prior to the procedure and LWA work as independent risk factors for AEs in these patients.

Polymorphism analysis and new JAG1 gene mutations of Alagille syndrome in Mexican population

Alagille syndrome is a multisystem disorder with an autosomic dominant pattern of inheritance that affects the liver, heart, eyes, kidneys, skeletal system and presents characteristic facial features. Mutations of the JAG1 gene have been identified in 20–89% of the patients with Alagille syndrome, this gene encodes for a ligand that activates the Notch signaling pathway. In the present study we analyzed 9 Mexican patients with Alagille syndrome who presented the clinical criteria for the classical presentation of the disease. By using the denaturing high performance liquid chromatography mutation analysis we were able to identify different mutations in 7 of the patients (77.77%), importantly, we found 5 novel mutations in JAG1 gene. The allelic frequency distribution of 13 polymorphisms in Mexican population is also reported. The overall results demonstrated an expanding mutational spectrum of JAG1 gene in the Mexican population.

Anesthetic considerations for the patient with liver disease

PURPOSE OF REVIEW

An increasing number of patients requiring surgery are presenting with chronic or end stage liver disease. The management of these patients demands anesthesiologists with in-depth knowledge of the consequences of hepatic dysfunction, the effects on other organs, the risk of surgery, and the impact of anesthesia.

RECENT FINDINGS

Chronic or end stage liver disease is associated with an increased risk of perioperative morbidity and mortality. It is essential to preoperatively assess possible hepatic encephalopathy, pleural effusions, hepatopulmonary syndrome, hepatopulmonary hypertension, hepatorenal syndrome, cirrhotic cardiomyopathy, and coagulation disorders. The application of two scoring systems, that is, Child-Turcotte-Pugh and model for end stage liver disease, helps to estimate the risk of surgery. The use of propofol is superior to benzodiazepines as intravenous narcotics. Although enflurane and halothane are discouraged for maintenance of anesthesia, all modern volatile anesthetics appear comparable with respect to outcome. Fentanyl, sufentanil, and remifentanil as opioids and cis-atracurium for relaxation may be the best choices in liver insufficency. Regional anesthesia is valuable for postoperative pain management.

SUMMARY

Current studies have employed different anesthetic approaches in the preoperative and intraoperative management in order to improve outcomes of patients with liver disease.