|Year : 2017 | Volume
| Issue : 3 | Page : 153-156
Anesthetic management for liver transplantation in small children
N Bhadrinath, R Halemani Kusuma
Department of Anaesthesia, Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
|Date of Web Publication||20-Dec-2017|
Dr. N Bhadrinath
A3 “SAYANA”; “SUHA” Residency, Poonthi Road, Kumarapuram, Thiruvananthapuram - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
Anesthetic and surgical management of small children is challenging because of technical difficulties and repeated re-explorations for vascular or biliary complications. Preoperative optimization and meticulous intraoperative and postoperative management can achieve the survival rates comparable to older children. In our institution, we have successfully managed living donor liver transplant in four small children ≤8 kg, and with these case reports, we have tried to present anesthetic concerns and management of these cases along with surgical and postoperative details.
Keywords: Anesthesia for liver transplant in children <8kg, anesthesia for pediatric liver transplant, pediatric liver transplant
|How to cite this article:|
Bhadrinath N, Kusuma R H. Anesthetic management for liver transplantation in small children. Indian J Transplant 2017;11:153-6
| Introduction|| |
In children undergoing liver transplantation, body weight is the determinant of outcome rather than age due to the presence of malnutrition and growth retardation secondary to liver disease. The smaller size, technical difficulties of the operation, higher rates of vascular and biliary complications, and postoperative re-explorations or infections make the transplantation in them challenging.
For anesthetists, these cases are unique because of their age, weight, liver failure, and associated systemic changes. Meticulous perioperative care, due care during and after re-explorations, leads to better outcome. We present four cases of pediatric liver transplantation in children ≤8 kg to highlight on this.
| Case Report|| |
From 2013 to 2016, a total of seven pediatric living donor liver transplants (LDLTs) were performed at our institution. Among these, four were children ≤8 kg. The smallest child was 6.5 kg, and the biggest was 8 kg. The preoperative details and investigations are presented in [Table 1].
The operating room (OR) was prewarmed to 25°C and was equipped with a warming mattress (hemotherm), fluid warmer, pressure bags, and emergency crash cart.
All children were put intravenous (IV) cannula before induction. Noninvasive standard monitors were attached, premedicated with IV glycopyrrolate and IV midazolam [Dose chart [Table 2], induced with IV fentanyl, IV Atracurium, and sevoflurane in oxygen inhalation. Oral microcuffed (Kimberly clark) endotracheal tube (ETT) was used for securing the airway. Cuff pressure was maintained around 10 cm of water. Radial arterial cannula was put after induction using 22-gauge (G) cannula (BD Insyte).
Anesthesia was maintained with sevoflurane in air–oxygen mixture, fentanyl, and atracurium infusion. Pressure-controlled mode was used for mechanical ventilation. The left femoral artery (20 G Insyte), a triple-lumen central line (5.5 French [F]) in the right internal jugular vein (IJV), and a double lumen central line (5F) in the left IJV were placed under ultrasound guidance.
Nasopharyngeal temperature, end-tidal carbon dioxide, urinary output, invasive arterial blood pressure (BP), and central venous pressure (CVP) were monitored continuously. Nasogastric tube (8–10 F) was put for continuous gastric drainage. Soft cotton roles were placed under the shoulder and knee to give knee flexion and neck extension. Laboratory parameters such as arterial blood gas, electrolytes, blood sugars, hemoglobin (Hb), prothrombin time, international normalization ratio (INR), and thromboelastography were monitored intraoperatively as and when required.
Maintenance IV fluid (plasmalyte + 2% dextrose) was administered through infusion pump. Replacement fluid (0.9% normal saline or 1% albumin), blood, and blood products were administered through syringe pumps. About 0.45% normal saline in burette set was used for correction of electrolytes, blood sugar, and acidosis. Blood and blood products (Goal: INR 1.5–2.5, platelet count >50,000, and Hb around 8 gm/dl) were used according to the need [Table 3]. CVP was maintained around 5–8 mmHg during the dissection phase and raised to 10 mmHg before reperfusion.
In all the patients, graft was taken from the left lateral lobe of the donor. One patient needed graft reduction (graft recipient weight ratio [GRWR] <4). University of Wisconsin solution was used for graft perfusion and preservation. During the anhepatic phase, the patient was optimized regarding serum electrolytes, acid–base status, and coagulopathy. IV methylprednisolone was administered in this phase. There was clinically no significant hemodynamic changes at the time of inferior vena cava (IVC) clamping. At reperfusion, there was a slight fall in BP, which responded to phenylephrine. One patient required redo of portal vein anastomosis.
Roux-en-Y hepaticojejunostomy was done for biliary drainage. In two patients, primary closure of the abdomen was possible, and in one patient, the abdomen was partially closed. The surgical and postoperative details are shown in [Table 3].
Postoperative details: All patients were closely monitored in the postoperative period with Doppler examination twice daily. Heparin infusion was started when INR was <2.5 and changed over to ecosprin tablets when it was safer from surgical point of view and platelets were >1 lakh/cmm. Activated partial thromboplastin time was maintained at 2–2.5.
The first and second patient had stable postoperative period. The third patient was re-explored twice for hepatic artery thrombosis (HAT). He was extubated on POD14 and put on nasal noninvasive ventilation (NIV) which was gradually weaned off. The fourth patient was re-explored on POD 3 for portal vein thrombosis (PVT). The abdomen was partially closed. On POD 4, he was re-explored for decreased hepatic arterial flow. Hepatic artery was repositioned, and the abdomen was left open. On POD12, his abdomen closure was done with the help of plastic surgeon. He was extubated on POD 23 and put on nasal NIV and gradually weaned off.
Re-explorations were managed with total IV anesthesia (TIVA) using propofol, fentanyl, and atracurium infusions in a well-prepared OR. Utmost aseptic precautions were maintained.
The first patient succumbed to respiratory infection 2.5-year posttransplant. Other three children are doing well till date.
| Discussion|| |
Living donor liver transplantation (LDLT) gives better patient and graft survival in small children because of availability of suitable-sized graft in a timely manner and lesser cold ischemia time., Advanced surgical techniques, new immunosuppression regimens, improved postoperative care, and early recognition and treatment of vascular and infectious complications , have improved the survival rates in these children.
Graft loss and retransplantation in small children can be prevented by using GRWR <4. Some case reports have shown that GRWR >4 can also be used., As larger graft will have its own problems such as inadequate portal blood flow, inability to close the abdomen, and PVT, we used reduced sized graft whenever the GRWR was >4.
Anesthetists have to deal with malnourished child with liver failure and its consequences. Prior surgery makes dissection phase longer and might lead to greater blood loss. Repeated blood sampling adds to this loss. Maintaining CVP around 5–8 mmHg during dissection phase and judicial laboratory testing using smaller vacutainers can prevent excessive blood loss. Overcorrection of Hb should be avoided to prevent HAT.
Microcuffed ETT with cuff pressure <10 cm H2O are proven to be safe in pediatric patients. They provide better ventilatory conditions and safety against aspiration. Hence, we preferred cuffed ETT.
Difficulty to access peripheral veins and fear of extravasation when fluids are administered through infusion pumps made us to use two central lines one in each IJV. Entangling of two lines or blocking flow in superior vena cava is the concern of such placements. To prevent this, we used smaller central line on the left side and limited its depth of insertion to 4–5 cm. We did not have any problem with this approach.
Acidosis, hypocalcemia, hypoglycemia, coagulopathy, and reduced urine output are seen during anhepatic phase. Small children tolerate clamping of the IVC better than adults. Venovenous bypass is not used in children of <10–15 kg because of the difficulty in maintaining adequate flow through the small cannulas.
Reperfusion can pose problems such as arrhythmias, high CVP, and hypotension. Smaller children are prone to hypothermia because of larger exposed surface area and prolonged surgery. The risk increases postreperfusion which is attributed to placement of cold graft and release of cold preservative fluid in the systemic circulation.
The duration of surgery can be longer due to difficult explant, anatomical mismatching of donor vessels and vascular thrombosis or kinking after the repositioning, which might require redo of the anastomoses such was the case with our first patient where redo of portal vein increased the duration by 130 min.
Primary closure of the abdomen can sometimes compromise the flow in hepatic vessels and cause graft dysoxia, graft congestion, partial liver necrosis, respiratory and renal failure., In two of our patients, we did primary closure as they had enough abdominal space. In one patient, the abdomen was partially closed which has to be reopened because of reduced hepatic arterial flow. In him, the abdomen was closed with the help of plastic surgeon on a later date.
These children are more prone to HAT or PVT and biliary leak in early postoperative period. A 50% decrease in the plasma concentrations of both protein C and antithrombin III and a 10-fold increase in plasminogen-activator inhibitor in the immediate postoperative period and smaller vessel size along with size disparity may be the cause for thrombosis. HAT remains an important cause of graft loss after pediatric liver transplantation. One of our patients had repeated HAT and another had kinking of hepatic artery. One patient had PVT.
When taken for re-explorations, TIVA was preferred to avoid inhalation agent-induced hepatotoxicity. Isoflurane or sevoflurane , anesthesia can also be used as these two agents cause hepatitis very rarely.
In our experience, vascular complications were the most common cause of re-explorations, and timely diagnosis and treatment was the key in better survival. Respiratory infections remained the most common cause of morbidity.
| Conclusion|| |
Pediatric liver transplantation is challenging to the anesthesiologists considering the patients' age, body weight, liver failure with multiorgan involvement, and major surgery. With careful intra- and postoperative care, we can achieve good survival after liver transplantation in smaller children as well.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]