Massive pulmonary hemorrhage before living donor liver transplantation in infants

Abstract

A massive pulmonary hemorrhage in patients with liver cirrhosis is a life-threatening complication that may result in a contraindication of a liver transplantation because of its high mortality rate. Herein, we present two infant biliary atresia cases that successfully underwent an LDLT that was followed by intensive respiratory care for the pretransplant massive pulmonary hemorrhage. Both cases exhibited severe respiratory failure (minimum PaO2/FiO2; 46 mmHg and 39 mmHg, respectively). To arrest the bleeding, we applied a very high positive pressure ventilation treatment (maximum PIP/PEEP; 38/14 cmH2O and 55/15 cmH2O, respectively), plasma exchange, several FFP transfusions, and recombinant factor VIIa via intrapulmonary administration. In addition, we used CHDF treatment, applied HFOV transiently, and treated the patient with inhalation of nitric oxide. Although we prepared ECMO for intra-operative use, both cases were successfully managed with conventional mechanical ventilation without using ECMO, which may have worsened the pulmonary hemorrhage due to the use of an anticoagulant. Use of an excessive positive pressure management, although it poses a risk for barotrauma, could be acceptable to arrest the pulmonary bleeding in selected cases of liver failure patients who have no time remaining before LDLT.

Multiple organ involvement and ICU considerations for the care of acute liver failure (ALF) and acute on chronic liver failure (ACLF) in children

“…Children with ALF or ACLF may develop acute hypoxemic respiratory failure and require endotracheal intubation for a myriad of reasons, including sepsis, volume overload, pulmonary hemorrhage, or acute respiratory distress syndrome (ARDS). Pulmonary hemorrhage, in particular, is considered a terminal stage of liver failure, and is associated with high mortality both pre-and post-transplant (20). In addition to management of overt acute respiratory failure, endotracheal intubation should be considered in children with grade III or IV HE who require airway protection due to neurologic failure (Table 3).…”