Transfusion requirements during cadaveric and living donor pediatric liver transplantation

Abstract

Surgical techniques that have been used during liver transplantation (LT) together with patient's coagulation profile and institutional practices are reported to have an effect on transfusion requirements. The aim of this study is to evaluate the transfusion requirement in both cadaveric (CDLT, n = 22) and living donor (LDLT, n = 24) pediatric LT performed in our institution. Balanced general anesthesia was used for all patients. Transfusion requirements were met to maintain a hemoglobin concentration of 8-10 g/dL, platelet level >50 x 10(3)/mL, prothrombin time <20 s and hemodynamic course with observing heart rate, arterial and central venous blood pressures and hourly urine output. Blood loss was replaced by using whole blood. Both groups' perioperative total blood and fresh-frozen plasma (FFP) volumes transfused, fluid requirements and hemodynamic courses, standard coagulation profile and metabolic variables determined in time periods of operations, patients' preoperative characteristics, operative features and postoperative events were compared. The mean transfusion requirements were 37.1 +/- 33.4 and 74.8 +/- 90.8 mL/kg of whole blood (p = 0.059) and 34.5 +/- 24.9 and 51.5 +/- 59.7 mL/kg of FFP for CDLT and LDLT, respectively (p = 0.519). The mean ages and mean body weights of the CDLT patients were higher than LDLT patients (9.7 +/- 5.3 vs. 6.6 +/- 4.4 yr, p = 0.015 and 32.4 +/- 17.7 vs. 21.0 +/- 14.8 kg, p = 0.032, respectively) while the mean operation time (493 +/- 135 vs. 323 +/- 93 min, p = 0.0001) and PELD score (13.1 +/- 11.2 vs. 20.1 +/- 11.8, p = 0.036) were higher for LDLT. In the entire population, multiple regression analysis showed that age, body weight and operation time have a significant combined effect on blood consumption (r2= 0.29, p = 0.003) meanwhile operation time was found to be an effective single variable (p = 0.002). None of the single or combined variables was found to have a significant effect on FFP consumption (r2= 0.17, p = 0.63) and crystalloid use (r2= 0.19, p = 0.11). Hemodynamic courses of both groups were similar. The incidences of metabolic acidosis and hypothermia during the anhepatic periods were higher in the CDLT group (p < 0.05). However, transfusion requirement in the ICU were higher in LDLT group [6.9 +/- 2.2 (n = 6) vs. 18.6 +/- 19 (n = 11) mL/kg, p < 0.05] after LT. As a result of this study in a pediatric patient population, no statistical significance was found in whole blood transfusion and FFP requirements between CDLT and LDLT. Duration of the operation was the primary factor effecting transfusion volume showing the importance of continued small volume losses during uncomplicated LT in this small sized patient population. Transfusion need for pediatric LT should be individualized for each patient based on the intraoperative conditions including surgical and patient features.

Longitudinal Study of Cognitive and Academic Outcomes after Pediatric Liver Transplantation

“…It is unclear whether operative transfusion volume was simply a marker for a less stable course during surgery or whether massive transfusion itself could have caused neurological injury. 30 Making that distinction would be fundamental in planning intervention strategies.…”

Anesthetic management in pediatric liver transplantation: a comparison of deceased or live donor liver transplantations

“…However, significantly fewer LDLT patients than DDLT patients required FFP. This study is a follow-up on two early reports [4,5]. It includes more patients, and the results are interesting in that they show an improvement in the success rate of early extubation and its relationship with other variables.…”

“…Also, if the TEG is normal, we routinely do not use FFP even though the PT is increased. In one of our earlier studies [4], which involved our first experience with 46 pediatric patients, the mean transfusion requirements were 75 and 37 ml/kg of whole blood and 51 and 34 ml/kg of FFP for LDLT and DDLT patients, respectively. However, the difference was not statistically significant for the groups in that study since only a small number of patients were included [4].…”

“…In one of our earlier studies [4], which involved our first experience with 46 pediatric patients, the mean transfusion requirements were 75 and 37 ml/kg of whole blood and 51 and 34 ml/kg of FFP for LDLT and DDLT patients, respectively. However, the difference was not statistically significant for the groups in that study since only a small number of patients were included [4]. In our study, in which we observed a marked lowering trend in RBC volumes compared with those reported in the previous study, the mean RBC (28 vs. 20 ml/kg), crystalloid (90 vs. 69 ml/kg), and colloid (32 ml/kg vs. 22 ml/kg) requirements were significantly higher in the LDLT patients than in the DDLT patients, respectively.…”

“…In order to successfully manage the anesthesia in these patients, it is particularly important that, depending on the stage of the procedure, the anesthetist must precisely correct for fluid and blood losses, constantly monitor electrolytes and blood gases, appropriately identify and correct bleeding diathesis, and maintain body temperature and diuresis [3]. In addition, perioperative management of these patients varies greatly between liver transplant centers in terms of fluid replacement, prevention and treatment of coagulopathy, transfusion requirements, and early extubation [4][5][6].…”