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Neto JS, Chapchap P, Feier FH, Pugliese R, Vincenzi R, Benavides MR, Roda K, Kondo M, Fonseca EA. The impact of low recipient weight [≤ 7kg] on long-term outcomes in 1078 pediatric living donor liver transplantations. J Pediatr Surg 2022; 57:955-961. [PMID: 35697543 DOI: 10.1016/j.jpedsurg.2022.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/11/2022] [Accepted: 05/18/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND infants who require liver transplantation represent a treatment challenge because chronic liver disease at this early age affects the child's growth and development during a critical phase. The aim is to compare demographics, operative data, and long-term outcomes according to recipient weight at the time of LDLT. METHODS This retrospective study included primary LDLT analyzed in 2 groups: BW ≤ 7 kg (n = 322) and BW > 7 kg (n = 756). A historical comparison between periods was also investigated. RESULTS BW ≤ 7 kg had significantly lower height/age and weight/age z-scores, with median PELD score of 19. Transfusion rates were higher in the BW ≤ 7 kg group (30.9 ml/kg versus 15.5 ml/kg, P < 0.001). Higher frequencies of PV complications were seen in the BW ≤ 7 kg cohort. HAT and retransplantation rates were similar. Those with BW ≤ 7 kg required longer ICU and hospital stays. Patient and graft survival were similar. Patient survival in BW≤ 7 kg was significantly better in the most recent period. CONCLUSION Malnutrition and advanced liver disease were more frequent in BW ≤ 7 kg. Despite increased rates of PVT and longer hospital stay, patient and graft long-term survival were similar between groups.
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Affiliation(s)
- João Seda Neto
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil.
| | - Paulo Chapchap
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil
| | - Flavia H Feier
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil
| | - Renata Pugliese
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Rodrigo Vincenzi
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Marcel R Benavides
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Karina Roda
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
| | - Mário Kondo
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil
| | - Eduardo A Fonseca
- Hepatology and Liver Transplantation, Hospital Sírio-Libanês, Rua Barata Ribeiro, 414, cj 65, Bela Vista, SP, Brazil; Hepatology and Liver Transplantation, A. C. Camargo Cancer Center, São Paulo, SP, Brazil; Hospital Municipal Infantil Menino Jesus, São Paulo, SP, Brazil
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Ballard HA, Jones E, Malavazzi Clemente MM, Damian D, Kovatsis PG. Educational Review: Error traps in anesthesia for pediatric liver transplantation. Paediatr Anaesth 2022; 32:1285-1291. [PMID: 36178188 PMCID: PMC9827908 DOI: 10.1111/pan.14565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/24/2022] [Accepted: 09/27/2022] [Indexed: 01/12/2023]
Abstract
Anesthetic and surgical techniques for the liver transplantation have progressed considerably over the past sixty years; however, this procedure is still fraught with substantial morbidity. To increase the safety culture associated with the liver transplantation, we detail nine error traps associated with anesthesia for pediatric liver transplantation. These potential pitfalls are divided into the operative phases: pre-operative preparation (Failure to have a dedicated anesthesia team for pediatric liver transplantation); pre-anhepatic (Failure to prepare for massive blood loss, Failure to monitor for coagulation abnormalities); anhepatic including reperfusion (Failure to prepare for clamping of the inferior vena cava, Failure to recognize metabolic changes, Failure to maintain homeostasis for reperfusion, Failure to prepare for Post-reperfusion syndrome); and post-anhepatic (Failure to optimize liver perfusion, Failure to maintain hemostatic balance). By offering practical advice on the preparation and treatment of these error traps, we aim to better prepare anesthesiologists to take care of pediatric patients undergoing the liver transplantation.
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Affiliation(s)
- Heather A. Ballard
- Department of Pediatric Anesthesiology, Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of MedicineChicagoILUSA
| | - Elin Jones
- Department of AnaesthesiaBirmingham Children's HospitalBirminghamUK
| | | | - Daniela Damian
- Department of AnesthesiologyUPMC Children's Hospital of Pittsburgh and University of Pittsburgh School of MedicinePittsburghPennsylvaniaUSA
| | - Pete G. Kovatsis
- Department of Anesthesiology, Critical Care and Pain MedicineBoston Children's Hospital and Department of Anaesthesia, Harvard Medical SchoolBostonMassachusettsUSA
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Villarreal JA, Yoeli D, Ackah RL, Sigireddi RR, Yoeli JK, Kueht ML, Galvan NTN, Cotton RT, Rana A, O'Mahony CA, Goss JA. Intraoperative blood loss and transfusion during primary pediatric liver transplantation: A single-center experience. Pediatr Transplant 2019; 23:e13449. [PMID: 31066990 DOI: 10.1111/petr.13449] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 03/05/2019] [Accepted: 04/03/2019] [Indexed: 01/28/2023]
Abstract
Children undergoing liver transplantation are at a significant risk for intraoperative hemorrhage and thrombotic complications, we aim to identify novel risk factors for massive intraoperative blood loss and transfusion in PLT recipients and describe its impact on graft survival and hospital LOS. We reviewed all primary PLTs performed at our institution between September 2007 and September 2016. Data are presented as n (%) or median (interquartile range). EBL was standardized by weight. Massive EBL and MT were defined as greater than the 85th percentile of the cohort. 250 transplantations were performed during the study period. 38 (15%) recipients had massive EBL, and LOS was 31.5 (15-58) days compared to 11 (7-21) days among those without massive EBL (P < 0.001). MT median LOS was 34 (14-59) days compared to 11 (7-21) days among those without MT (P = 0.001). Upon backward stepwise regression, technical variant graft, operative time, and transfusion of FFP, platelet, and/or cryoprecipitate were significant independent risk factors for massive EBL and MT, while admission from home was a protective factor. Recipient weight was a significant independent risk factor for MT alone. Massive EBL and MT were not statistically significant for overall graft survival. MT was, however, a significant risk factor for 30-day graft loss. PLT recipients with massive EBL or MT had significantly longer LOS and increased 30-day graft loss in patients who required MT. We identified longer operative time and technical variant graft were significant independent risk factors for massive EBL and MT, while being admitted from home was a protective factor.
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Affiliation(s)
- Joshua A Villarreal
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Dor Yoeli
- Department of Surgery, University of Colorado Denver, Aurora, Colorado
| | - Ruth L Ackah
- Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Rohini R Sigireddi
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Jordan K Yoeli
- Department of Surgery, University of Colorado Denver, Aurora, Colorado
| | - Michael L Kueht
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - N Thao N Galvan
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Ronald T Cotton
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Abbas Rana
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Christine A O'Mahony
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - John A Goss
- Division of Abdominal Transplantation, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
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4
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Zhang L, Tian M, Xue F, Zhu Z. Diagnosis, Incidence, Predictors and Management of Postreperfusion Syndrome in Pediatric Deceased Donor Liver Transplantation: A Single-Center Study. Ann Transplant 2018; 23:334-344. [PMID: 29773782 PMCID: PMC6248285 DOI: 10.12659/aot.909050] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Postreperfusion syndrome (PRS) is a dreadful and well-documented complication in adult liver transplantation (LT). However, information regarding PRS in pediatric LT is still scarce. We aimed to identify the incidence, risk factors and associated outcomes of pediatric LT in a single-center study. Material/Methods The medical records of 75 consecutive pediatric patients who underwent deceased donor liver transplantation (DDLT) from July 2015 to October 2017 were retrospectively reviewed. PRS was determined according to the Peking criteria when significant arrhythmia or refractory hypotension occurred following revascularization of the liver graft. Patients were divided into PRS and non-PRS groups. Preoperative, intraoperative, and postoperative data were collected and compared between the 2 groups. Independent risk factors for PRS were analyzed using binary logistic regression analysis. Results PRS occurred in 26 patients (34.7%). Univariate analysis showed that the graft-to-recipient weight ratio (P=0.023), donor warm ischemia time (P<0.001), and the use of an expanded criteria donor (ECD) liver graft (P<0.001) were significant predictors of PRS. Binary logistic regression showed that the use of an ECD liver graft (odds ratio [OR]: 18.668; 95% confidence interval [95% CI]: 4.866–71.622) and lower hematocrit (HCT) level before reperfusion (OR: 0.878; 95% CI: 0.782–0.985) were independent predictors of PRS. PRS was significantly associated with early allograft dysfunction (73.1% vs. 18.4%, P<0.001), primary nonfunction (11.5% vs. 0.0%, P=0.039), and a prolonged hospital stay (median: 30.5 vs. 21.0, P=0.007). Conclusions The use of an ECD liver graft and lower HCT level before reperfusion were independent risk factors for PRS in pediatric DDLT. Intraoperative PRS occurrence seems to be associated with poor liver allograft function and worsened patient postoperative outcomes.
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Affiliation(s)
- Liang Zhang
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ming Tian
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Fushan Xue
- Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland)
| | - Zhijun Zhu
- Division of Liver Transplantation Surgery, Department of Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China (mainland).,Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing, China (mainland)
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5
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Jin SJ, Kim SK, Choi SS, Kang KN, Rhyu CJ, Hwang S, Lee SG, Namgoong JM, Kim YK. Risk factors for intraoperative massive transfusion in pediatric liver transplantation: a multivariate analysis. Int J Med Sci 2017; 14:173-180. [PMID: 28260994 PMCID: PMC5332847 DOI: 10.7150/ijms.17502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 12/21/2016] [Indexed: 01/10/2023] Open
Abstract
Background: Pediatric liver transplantation (LT) is strongly associated with increased intraoperative blood transfusion requirement and postoperative morbidity and mortality. In the present study, we aimed to assess the risk factors associated with massive transfusion in pediatric LT, and examined the effect of massive transfusion on the postoperative outcomes. Methods: We enrolled pediatric patients who underwent LT between December 1994 and June 2015. Massive transfusion was defined as the administration of red blood cells ≥100% of the total blood volume during LT. The cases of pediatric LT were assigned to the massive transfusion or no-massive transfusion (administration of red blood cells <100% of the total blood volume during LT) group. Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors associated with massive transfusion in pediatric LT. Kaplan-Meier survival analysis, with the log rank test, was used to compare graft and patient survival within 6 months after pediatric LT between the 2 groups. Results: The total number of LT was 112 (45.0%) and 137 (55.0%) in the no-massive transfusion and massive transfusion groups, respectively. Multivariate logistic regression analysis indicated that high white blood cell (WBC) count, low platelet count, and cadaveric donors were significant predictive factors of massive transfusion during pediatric LT. The graft failure rate within 6 months in the massive transfusion group tended to be higher than that in the no-massive transfusion group (6.6% vs. 1.8%, P = 0.068). However, the patient mortality rate within 6 months did not differ significantly between the massive transfusion and no-massive transfusion groups (7.3% vs. 7.1%, P = 0.964). Conclusion: Massive transfusion during pediatric LT is significantly associated with a high WBC count, low platelet count, and cadaveric donor. This finding can provide a better understanding of perioperative blood transfusion management in pediatric LT recipients.
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Affiliation(s)
- Seok-Joon Jin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun-Key Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Keum Nae Kang
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Chang Joon Rhyu
- Department of Anesthesiology and Pain Medicine, National Police Hospital, Seoul, Republic of Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Gyu Lee
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Fanna M, Baptiste A, Capito C, Ortego R, Pacifico R, Lesage F, Moulin F, Debray D, Sissaoui S, Girard M, Lacaille F, Telion C, Elie C, Aigrain Y, Chardot C. Preoperative risk factors for intra-operative bleeding in pediatric liver transplantation. Pediatr Transplant 2016; 20:1065-1071. [PMID: 27681842 DOI: 10.1111/petr.12794] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2016] [Indexed: 12/20/2022]
Abstract
This study analyzes the preoperative risk factors for intra-operative bleeding in our recent series of pediatric LTs. Between November 2009 and November 2014, 84 consecutive isolated pediatric LTs were performed in 81 children. Potential preoperative predictive factors for bleeding, amount of intra-operative transfusions, postoperative course, and outcome were recorded. Cutoff point for intra-operative HBL was defined as intra-operative RBC transfusions ≥1 TBV. Twenty-six patients (31%) had intra-operative HBL. One-year patient survival after LT was 66.7% (CI 95%=[50.2-88.5]) in HBL patients and 83.8% (CI 95%=[74.6-94.1]) in the others (P=.054). Among 13 potential preoperative risk factors, three of them were identified as independent predictors of high intra-operative bleeding: abdominal surgical procedure(s) prior to LT, factor V level ≤30% before transplantation, and ex situ parenchymal transsection of the liver graft. Based on these findings, we propose a simple score to predict the individual hemorrhagic risk related to each patient and graft association. This score may help to better anticipate intra-operative bleeding and improve patient's management.
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Affiliation(s)
- Martina Fanna
- Pediatric surgery unit, Hôpital Necker enfants malades, Paris, France
| | - Amandine Baptiste
- Clinical research unit, Hôpital Necker enfants malades, Paris, France
| | - Carmen Capito
- Pediatric surgery unit, Hôpital Necker enfants malades, Paris, France
| | - Rocio Ortego
- Anesthesiology unit, Hôpital Necker enfants malades, Paris, France
| | | | - Fabrice Lesage
- Intensive care unit, Hôpital Necker enfants malades, Paris, France
| | - Florence Moulin
- Intensive care unit, Hôpital Necker enfants malades, Paris, France
| | | | - Samira Sissaoui
- Hepatology unit, Hôpital Necker enfants malades, Paris, France
| | - Muriel Girard
- Hepatology unit, Hôpital Necker enfants malades, Paris, France
| | | | - Caroline Telion
- Anesthesiology unit, Hôpital Necker enfants malades, Paris, France
| | - Caroline Elie
- Clinical research unit, Hôpital Necker enfants malades, Paris, France
| | - Yves Aigrain
- Pediatric surgery unit, Hôpital Necker enfants malades, Paris, France
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Nacoti M, Corbella D, Fazzi F, Rapido F, Bonanomi E. Coagulopathy and transfusion therapy in pediatric liver transplantation. World J Gastroenterol 2016; 22:2005-23. [PMID: 26877606 PMCID: PMC4726674 DOI: 10.3748/wjg.v22.i6.2005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 11/23/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Bleeding and coagulopathy are critical issues complicating pediatric liver transplantation and contributing to morbidity and mortality in the cirrhotic child. The complexity of coagulopathy in the pediatric patient is illustrated by the interaction between three basic models. The first model, "developmental hemostasis", demonstrates how a different balance between pro- and anticoagulation factors leads to a normal hemostatic capacity in the pediatric patient at various ages. The second, the "cell based model of coagulation", takes into account the interaction between plasma proteins and cells. In the last, the concept of "rebalanced coagulation" highlights how the reduction of both pro- and anticoagulation factors leads to a normal, although unstable, coagulation profile. This new concept has led to the development of novel techniques used to analyze the coagulation capacity of whole blood for all patients. For example, viscoelastic methodologies are increasingly used on adult patients to test hemostatic capacity and to guide transfusion protocols. However, results are often confounding or have limited impact on morbidity and mortality. Moreover, data from pediatric patients remain inadequate. In addition, several interventions have been proposed to limit blood loss during transplantation, including the use of antifibrinolytic drugs and surgical techniques, such as the piggyback and lowering the central venous pressure during the hepatic dissection phase. The rationale for the use of these interventions is quite solid and has led to their incorporation into clinical practice; yet few of them have been rigorously tested in adults, let alone in children. Finally, the postoperative period in pediatric cohorts of patients has been characterized by an enhanced risk of hepatic vessel thrombosis. Thrombosis in fact remains the primary cause of early graft failure and re-transplantation within the first 30 d following surgery, and it occurs despite prolongation of standard coagulation assays. Data, however, are currently lacking regarding the use of anti-aggregation/anticoagulation therapies and how to best monitor for thrombosis in the early postoperative period in pediatric patients. Therefore, further studies are necessary to elucidate the interaction between the development of the coagulation system and cirrhosis in children. Moreover, strategies to optimize blood transfusion and anticoagulation must be tested specifically in pediatric patients. In conclusion, data from the adult world can be translated with difficulty into the pediatric field as indication for transplantation, baseline pathologies and levels of pro- and anticoagulation factors are not comparable between the two populations.
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8
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Sorensen LG, Neighbors K, Martz K, Zelko F, Bucuvalas JC, Alonso EM. Longitudinal study of cognitive and academic outcomes after pediatric liver transplantation. J Pediatr 2014; 165:65-72.e2. [PMID: 24801243 PMCID: PMC4152855 DOI: 10.1016/j.jpeds.2014.03.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 02/28/2014] [Accepted: 03/19/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the evolution of cognitive and academic deficits and risk factors in children after liver transplantation. STUDY DESIGN Patients ≥2 years after liver transplantation were recruited through Studies of Pediatric Liver Transplantation. Participants age 5-6 years at Time 1 completed the Wechsler Preschool and Primary Scale of Intelligence, 3rd edition, Wide Range Achievement Test, 4th edition, and Behavior Rating Inventory of Executive Function (BRIEF). Participants were retested at age 7-9 years, Time 2 (T2), by use of the Wechsler Intelligence Scales for Children, 4th edition, Wide Range Achievement Test, 4th edition, and BRIEF. Medical and demographic variables significant at P ≤ .10 in univariate analysis were fitted to repeated measures modeling predicting Full Scale IQ (FSIQ). RESULTS Of 144 patients tested at time 1, 93 (65%) completed T2; returning patients did not differ on medical or demographic variables. At T2, more participants than expected had below-average FSIQ, Verbal Comprehension, Working Memory, and Math Computation, as well as increased executive deficits on teacher BRIEF. Processing Speed approached significance. At T2, 29% (14% expected) had FSIQ = 71-85, and 7% (2% expected) had FSIQ ≤70 (P = .0001). A total of 42% received special education. Paired comparisons revealed that, over time, cognitive and math deficits persisted; only reading improved. Modeling identified household status (P < .002), parent education (P < .01), weight z-score at liver transplantation (P < .03), and transfusion volume during liver transplantation (P < .0001) as predictors of FSIQ. CONCLUSIONS More young liver transplantation recipients than expected are at increased risk for lasting cognitive and academic deficits. Pretransplant markers of nutritional status and operative complications predicted intellectual outcome.
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Affiliation(s)
- Lisa G. Sorensen
- Child & Adolescent Psychiatry, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Katie Neighbors
- Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | | | - Frank Zelko
- Child & Adolescent Psychiatry, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - John C. Bucuvalas
- Pediatric Liver Care Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Estella M. Alonso
- Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
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9
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The population pharmacokinetics of fentanyl in patients undergoing living-donor liver transplantation. Clin Pharmacol Ther 2011; 90:423-31. [PMID: 21814196 DOI: 10.1038/clpt.2011.133] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Fentanyl, an opioid analgesic with a high hepatic extraction ratio, is frequently used to supplement general anesthesia during liver transplantation and is also continuously infused to provide postoperative analgesia. However, because fentanyl is metabolized mainly in the liver, the pharmacokinetics of fentanyl may vary widely during the different phases of the surgery, potentially leading to adverse events. Using nonlinear mixed-effects modeling, we characterized the pharmacokinetics of fentanyl in 15 patients (American Society of Anesthesiologists Physical Status Classification 2 or 3) undergoing living-donor liver transplantation (LDLT). Fentanyl was continuously infused at the rate of 200-400 µg/h throughout the operation. The time course of the fentanyl plasma concentration levels was best described in terms of a two-compartment model. Estimates were made of the pharmacokinetic parameters during the preanhepatic, anhepatic, and neohepatic phases: central volume of distribution (V(1)) (l): 59.0 + hourly volume infused by rapid infusion system (RIS) × 42.5, 113.0, and 189.0, respectively, × (body weight/69)(1.3); peripheral volume of distribution (V(2)) (l): 94.3, 412.0, and 427.0, respectively; intercompartmental clearance (Q) (l/h): 96.4 × (cardiac output (CO)/6.7)(2.5), 22.6, and 28.2, respectively; metabolic clearance (Cl) (l/h): 21.7 during the preanhepatic and neohepatic phases, and 0 during the anhepatic phase. The preanhepatic central volume of distribution was found to be markedly influenced by the massive infusion of fluids and blood products. The more hyperdynamic the circulation was during the preanhepatic phase, the higher the distributional clearance.
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Anesthetic management in pediatric liver transplantation: a comparison of deceased or live donor liver transplantations. J Anesth 2010; 24:399-406. [PMID: 20339881 DOI: 10.1007/s00540-010-0928-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 02/26/2010] [Indexed: 12/22/2022]
Abstract
PURPOSE Pediatric liver transplantations (LT) are becoming increasingly more common in the treatment of a child with end-stage liver disease. The aim of this study was to evaluate the perioperative anesthetic experience of pediatric patients undergoing deceased and live donor liver transplantations. METHODS We performed a chart review of 164 patients between December 1997 and February 2009 in a retrospective cohort study design. Patient characteristics, operational variables, hemodynamic course, blood and fluid requirements, and extubation rates were evaluated in both deceased [deceased donor liver transplantation (DDLT, n = 56)] and live donor liver transplantation (LDLT, n = 101) patients. RESULTS The LDLT patients had a lower mean age and body weight than the DDLT patients (p < 0.05). The mean operation time was significantly longer and the mean anhepatic time was shorter for LDLT patients than for DDLT patients. The mean red blood cell (RBC) count and crystalloid and colloid requirements were significantly higher in LDLT patients. Relative to DDLT patients, significantly more patients in the LDLT group did not require fresh frozen plasma. The overall success rates of immediate extubation at the end of surgery were 74% in LDLT patients and 49% in DDLT patients (p = 0.086). The immediate extubation rate by year, including both groups, increased from 0% in 1997 to 95.6% in 2008. CONCLUSION The results of this study show that among pediatric patients LDLT continues to become an 'obligatory' option that is associated with longer operation times and higher RBC and fluid requirements than DDLT. As a marker of successful LT, higher extubation rates immediately following surgery is achievable for both pediatric LDLT and DDLT patients.
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11
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Liang TB, Bai XL, Li DL, Li JJ, Zheng SS. Early postoperative hemorrhage requiring urgent surgical reintervention after orthotopic liver transplantation. Transplant Proc 2007; 39:1549-53. [PMID: 17580186 DOI: 10.1016/j.transproceed.2007.01.080] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2006] [Revised: 11/07/2006] [Accepted: 01/29/2007] [Indexed: 12/14/2022]
Abstract
Hemorrhage is a common complication in the early postoperative period after orthotopic liver transplantation (OLT) and surgical reintervention may be necessary. We sought to assess the incidence as well as to identify potential risk factors for bleeding requiring surgical reintervention in the early postoperative period. From January 2003 to December 2005, we retrospectively reviewed the courses of 261 patients who underwent OLT. We analyzed the pretransplantation parameters, transplantation features, and clinical data for surgical reintervention due to early postoperative hemorrhage. Twenty-two of 261 patients (8.4%) had early postoperative hemorrhage requiring urgent surgical reintervention during the initial hospital stay. In-hospital mortality of the patients with hemorrhage (9/22; 41%) was significantly higher than that of other patients (29/239; 12.1%; P < .001). The surgical problem was the main cause of hemorrhage (18/22; 81.8%). More intraoperative blood transfusions were necessary for patients with hemorrhage than for other patients. Furthermore, a greater number of blood transfusions, including red blood cells, plasma, and platelet concentrates, during the transplantation procedure correlated with a greater mortality. In conclusion, early postoperative hemorrhage requiring urgent surgical reintervention is a severe complication with a high mortality. It is mainly caused by errors in surgical technique. Blood transfusion during transplantation was correlated with a higher mortality.
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Affiliation(s)
- T B Liang
- Department of Hepatobiliary and Pancreatic Surgery, Key Lab of Combined Multi-organ Transplantation, Ministry of Public Health, the First Affiliated Hospital of Medical College, Zhejiang University, Hangzhou, People's Republic of China
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