Intraoperative Anesthetic Challenges in Pediatric Liver Transplantation
Maryam Taha Ibrahim Elsheikh;
Abstract
Pediatric liver transplant started in late sixties and after the introduction of cyclosporine drugs (immuno- suppressive drugs), it increased profoundly. The most common indications for pediatric liver transplant are biliary atresia, metabolic diseases of the liver, fulminant hepatic failure, hepatic tumors and retransplantaion for hepatic graft failure.
The preoperative evaluation for pediatric liver transplant includes mainly assessment of all organ systems to determine the presence and degree of impairment. In addition, it diagnosis other associated abnormalities such as cardiac problems. Cardiac catheterization is done to determine the degree of pulmonary hypertension and assess right ventricular function. Furthermore, patients with significant abnormalities of other organ systems unrelated to the liver disease need to be assessed for appropriateness for liver transplantation.
For intra-operative concerns, after induction of anesthesia, patient's extremities and head are padded and wrapped to minimize heat loss. Patient is placed on a warmer, with toe and esophageal probes for temperature. Anesthesia is maintained by a combination of inhalational agents, opioids and non¬depolarizing muscle relaxants.
The stages of surgery include dissection phase, anhepatic phase and reperfusion phase. During dissection phase, arterial blood gases, serum electrolyte, glucose and hematocrite values are assessed every 1-2 hours. In patients with prolonged PT, INR and PTT, fresh frozen plasma is infused to maintain adequate intravascular volume. In the anhepatic phase, fluid administration should be limited for adequate tissue perfusion, and adequate cardiac output. Also sodium bicarbonate may be given to neutralize pH changes.
Reperfusion phase is the period of greatest risk of hypotension which may occur immediately following reperfusion of allograft. This circulatory disturbance includes arterial hypotension, bradycardia, ventricular dysrythmias and cardiac arrest. These changes are provoked by rapid infusion of effluent from the transplanted liver which is high in potassium and low in pH and temperature. In addition, infusion of air and/or micro-thrombi into the heart may precipitate acute pulmonary hypertension. Correction of the problems prevents these complications.
Monitoring in the early postoperative period includes detailed analysis of laboratory data such as CBC, ABG and electrolytes every 2 hours. Other monitors can be done every 8 hours (e.g. BUN, SGOT, creatine, PT, PTT). While seralogy and PCR are done weakly. CVP, ABP and oxygen are continuously monitored in the post operative days.
The preoperative evaluation for pediatric liver transplant includes mainly assessment of all organ systems to determine the presence and degree of impairment. In addition, it diagnosis other associated abnormalities such as cardiac problems. Cardiac catheterization is done to determine the degree of pulmonary hypertension and assess right ventricular function. Furthermore, patients with significant abnormalities of other organ systems unrelated to the liver disease need to be assessed for appropriateness for liver transplantation.
For intra-operative concerns, after induction of anesthesia, patient's extremities and head are padded and wrapped to minimize heat loss. Patient is placed on a warmer, with toe and esophageal probes for temperature. Anesthesia is maintained by a combination of inhalational agents, opioids and non¬depolarizing muscle relaxants.
The stages of surgery include dissection phase, anhepatic phase and reperfusion phase. During dissection phase, arterial blood gases, serum electrolyte, glucose and hematocrite values are assessed every 1-2 hours. In patients with prolonged PT, INR and PTT, fresh frozen plasma is infused to maintain adequate intravascular volume. In the anhepatic phase, fluid administration should be limited for adequate tissue perfusion, and adequate cardiac output. Also sodium bicarbonate may be given to neutralize pH changes.
Reperfusion phase is the period of greatest risk of hypotension which may occur immediately following reperfusion of allograft. This circulatory disturbance includes arterial hypotension, bradycardia, ventricular dysrythmias and cardiac arrest. These changes are provoked by rapid infusion of effluent from the transplanted liver which is high in potassium and low in pH and temperature. In addition, infusion of air and/or micro-thrombi into the heart may precipitate acute pulmonary hypertension. Correction of the problems prevents these complications.
Monitoring in the early postoperative period includes detailed analysis of laboratory data such as CBC, ABG and electrolytes every 2 hours. Other monitors can be done every 8 hours (e.g. BUN, SGOT, creatine, PT, PTT). While seralogy and PCR are done weakly. CVP, ABP and oxygen are continuously monitored in the post operative days.
Other data
| Title | Intraoperative Anesthetic Challenges in Pediatric Liver Transplantation | Other Titles | التحديات التخديرية أثناء زراعة الكبد فى الأطفال | Authors | Maryam Taha Ibrahim Elsheikh | Issue Date | 2015 |
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