Intraoperative fluid administration volumes during pediatric liver transplantation and postoperative outcomes: A multicenter analysis

Abstract

Introduction Fluid administration is an important aspect of the management of children undergoing liver transplantation and may impact postoperative outcomes. Our aim was to evaluate the association between volume of intraoperative fluid administration and our primary outcome, the duration of postoperative mechanical ventilation following pediatric liver transplantation. Secondary outcomes included intensive care unit length of stay and hospital length of stay. Methods We conducted a multicenter, retrospective cohort study using electronic data from three major pediatric liver transplant centers. Intraoperative fluid administration was indexed to weight and duration of anesthesia. Univariate and stepwise linear regression analyses were conducted. Results Among 286 successful pediatric liver transplants, the median duration of postoperative mechanical ventilation was 10.8 h (IQR 0.0, 35.4), the median intensive care unit length of stay was 4.3 days (IQR 2.7, 6.8), and the median hospital length of stay was 13.6 days (9.8, 21.1). Univariate linear regression showed a weak correlation between intraoperative fluids and duration of ventilation (r2 = .037, p = .001). Following stepwise linear regression, intraoperative fluid administration remained weakly correlated (r2 = .161, p = .04) with duration of postoperative ventilation. The following variables were also independently correlated with duration of ventilation: center (Riley Children's Health versus Children's Health Dallas, p = .001), and open abdominal incision after transplant (p = .001). Discussion The amount of intraoperative fluid administration is correlated with duration of postoperative mechanical ventilation in children undergoing liver transplantation, however, it does not seem to be a strong factor. Conclusions Other modifiable factors should be sought which may lead to improved postoperative outcomes in this highly vulnerable patient population.

Anesthesia Management For Pediatric Liver Transplantation: Narrative Review

“…Perioperative Period Human serum albumin is still the best colloidal solution in general fluid management during LT. Human albumin is given to expand the volume, retain fluid in the vein, and maintain oncotic pressure while increasing its concentration in children with protein levels and bulky acidity. The non-lactic acid compound sodium acetate is also a suitable crystalloid for LT [26]. Because of the potential for hyperchloric metabolic acidosis, normal saline is not recommended for patients with pediatric LT [27].…”

“…Hyponatremia is a common finding in patients with ESLD and should not be corrected quickly because it causes central pons demyelination, which may result in cerebral edema and changes in consciousness. Therefore, it is more appropriate to use low Na + liquids [26][27][28]. The risk of hypoglycemia is higher during pediatric LT, so we routinely use 100 mL of 5% dextrose at baseline and adjust the rate to blood glucose levels Pediatric LT presents many challenges for the anesthesiologist, requiring specialized knowledge, experience, and highly specialized intraoperative management.…”

“…Volume loading may cause pulmonary edema, abnormal gas exchange, congestion, decreased perfusion, and graft edema. Monitoring with PiCCO as needed during all phases of LT provides many advantages in hemodynamic parameters and fluid management [15,16,[25][26][27]. PICU stay, morbidity, and mortality can be reduced thanks to careful fluid management.…”

Trends in sedation‐analgesia practices in pediatric liver transplant patients admitted postoperatively to the pediatric intensive care unit: An analysis of data from the pediatric health information system (PHIS) database

“…The immediate postoperative period in the PICU for the recipient of the liver transplant can be unpredictable in terms of respiratory and hemodynamic stability, renal and hepatic function, absorption capability of the gastrointestinal tract, alteration in the pharmacokinetics, pharmacodynamics, protein binding, and drug–drug interactions. Additionally, the preservation and optimal functioning of the newly transplanted organ is a top priority during this perioperative period in the PICU 6–8 …”

“…Additionally, the preservation and optimal functioning of the newly transplanted organ is a top priority during this perioperative period in the PICU. [6][7][8] Pediatric intensivists must balance the management of pain and sedation in these critically ill patients, as oversedation can lead to reintubation, or delayed extubation thereby lengthening the stay in the PICU and the hospital. 9 Oversedation can have negative effects on patient hemodynamics thereby compromising blood flow to the newly transplanted organ.…”