Maintenance of Ionized Calcium During Prolonged Extreme Massive Transfusion During Liver Transplantation.

INTRODUCTION: Massive transfusion may cause ionized hypocalcemia, a complication that, when severe, causes hemodynamic instability. Extant literature fails to provide effective guidance on replacement strategies to avoid severe ionized hypocalcemia in the most extreme situations. CASE PRESENTATION: We discuss a liver transplant in which our empiric calcium replacement strategy resulted in no critically low ionized calcium values during the pre-reperfusion phase of a liver transplant with over 140 000 mL of bank blood transfusion, with an average of 10 000 mL per hour for 14 hours. DISCUSSION: Few comparable reports exist. Most rely upon monitoring with subsequent replacement, but these have not been effective at avoiding severely low ionized calcium values. CONCLUSIONS: Our empiric calcium replacement strategy of 1 gram of calcium chloride per liter of citrated bank blood transfused, in 200 mg/200 mL increments, resulted in successful maintenance of ionized calcium during the anhepatic phase of liver transplantation while on continuous veno-venous hemofiltration.

Hepatic artery flow, inspired oxygen, and hemoglobin determine liver tissue saturation measured with visible diffuse reflectance spectroscopy (vis-DRS) in an in vivo swine model.

BACKGROUND: Prompt diagnosis of vascular compromise following pediatric liver transplantation and restoration of oxygen delivery to the liver improves organ survival. vis-DRS allows for real-time measurement of liver tissue saturation. METHODS: The current study used vis-DRS to determine changes in liver saturation during clinically relevant conditions of reduced oxygen delivery. In an in vivo swine model (n = 15), we determined liver tissue saturation (St O2 ) during stepwise reduction in hepatic artery flow, different inspiratory oxygen fraction (FiO2 ), and increasing hemodilution. A custom vis-DRS probe was placed directly on the organ. RESULTS: Liver tissue saturation decreased significantly with a decrease in hepatic artery flow. A reduction in hepatic artery flow to 25% of baseline reduced the St O2 by 15.3 ± 1.4% at FiO2 0.3 (mean ± SE, p < .0013), and by 8.3 ± 1.9% at FiO2 1.0 (p = .0013). After hemodilution to 7-8 g/dl, St O2 was reduced by 31.8% ± 2.7%, p < .001 (FiO2 0.3) and 26.6 ± 2.7%, p < .001 (FiO2 : 1.0) respectively. Portal venous saturation during low hepatic artery flow was consistently higher at FiO2 1.0. The gradient between portal venous saturation and liver tissue saturation was consistently greater at lower hemoglobin levels (7.0 ± 1.6% per g/dl hemoglobin, p < .001). CONCLUSIONS: Vis-DRS showed prompt changes in liver tissue saturation with decreases in hepatic artery blood flow. At hepatic artery flows below 50% of baseline, liver saturation depended on FiO2 and hemoglobin concentration suggesting that during hepatic artery occlusion, packed red blood cell transfusion and increased FiO2 may be useful measures to reduce hypoxic damage until surgical revascularization.

Use of Liposomal Bupivacaine in Pediatric Peripheral Nerve Blocks after Traumatic Amputation.

Liposomal bupivacaine has been explored for indications in regional anesthesia, but little has been reported about its use in pediatric patients. In March 2021, the FDA approved an indication for liposomal bupivacaine as an infiltrated local anesthetic in children older than the age of six. Despite this recently expanded indication, the literature lacks reports of use for peripheral nerve blockade in children. We describe a case where liposomal bupivacaine was used for femoral and sciatic nerve blocks in a 5-year-old child with traumatic amputation of his lower leg. Pain control was excellent, with no pain or opioid use reported during the first 62 hours. After the regional anesthesia subsided, the patient required in total 4 oral doses of oxycodone 0.1 mg/kg prior to discharge. The patient did not develop chronic pain or phantom limb syndrome. While liposomal bupivacaine is not currently FDA-approved for peripheral nerve blockade in children, this case highlights a potentially effective use of this drug and possible area for further investigation.

Evaluation of visible diffuse reflectance spectroscopy in liver tissue: validation of tissue saturations using extracorporeal circulation.

SIGNIFICANCE: Real-time information about oxygen delivery to the hepatic graft is important to direct care and diagnose vascular compromise in the immediate post-transplant period. AIM: The current study was designed to determine the utility of visible diffuse reflectance spectroscopy (vis-DRS) for measuring liver tissue saturation in vivo. APPROACH: A custom-built vis-DRS probe was calibrated using phantoms with hemoglobin (Hb) and polystyrene microspheres. Ex vivo (extracorporeal circulation) and in vivo protocols were used in a swine model (n = 15) with validation via blood gas analysis. RESULTS: In vivo absorption and scattering measured by vis-DRS with and without biliverdin correction correlated closely between analyses. Lin's concordance correlation coefficients are 0.991 for µa and 0.959 for µs ' . Hb measured by blood test and vis-DRS with (R2 = 0.81) and without (R2 = 0.85) biliverdin correction were compared. Vis-DRS data obtained from the ex vivo protocol plotted against the PO2 derived from blood gas analysis showed a good fit for a Hill coefficient of 1.67 and P50 = 34 mmHg (R2 = 0.81). A conversion formula was developed to account for the systematic deviation, which resulted in a goodness-of-fit R2 = 0.76 with the expected oxygen dissociation curve. CONCLUSIONS: We show that vis-DRS allows for real-time measurement of liver tissue saturation, an indicator for liver perfusion and oxygen delivery.

Retrieving multiple magnetic foreign bodies from the glottic entrance and stomach: A case report.

Aspiration and ingestion of foreign bodies present a frequent challenge in pediatric anesthesia practice that requires careful planning of the time and the method of retrieval. We discuss the management of a 20-month-old boy who had ingested multiple small magnetic beads and presented emergently to the operating room with two beads lodged in the vallecula and eighteen more forming a chain in the stomach. Benefitting from their magnetic properties, the beads located close to the glottic entrance could be removed by placing a steel Magill forceps close to the objects and using magnetic pull rather than grasping. The beads in the stomach were removed en bloc due to their magnetic properties using an endoscopic retrieval basket. Small beads can be difficult to remove, however, in this case it was possible to utilize their magnetic properties during the removal process.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery.

We describe the use of liposomal bupivacaine (Exparel) in erector spinae plane blocks for two patients undergoing pediatric cardiac surgery with cardiopulmonary bypass and one undergoing division of the compressive vascular ring. The perioperative course of all patients was remarkable for low pain and sedation scores, especially after chest tube removal. Erector spinae plane blocks are an expanding pain-control technique in both adult and pediatric cardiac surgery for postoperative analgesia. Liposomal bupivacaine offers prolonged analgesia and may be an attractive option for this indication.

Variation in immunosuppression practices among pediatric liver transplant centers-Society of Pediatric Liver Transplantation survey results.

BACKGROUND: Variation in IS exists among pediatric liver transplant centers. While individual centers may publish their practice paradigms, current data on practices as a whole are lacking. This study sought to ascertain the IS protocols of pediatric liver transplant centers within the SPLIT to better understand variability and similarities among peer institutions. METHODS: A 27-item questionnaire was developed within the SPLIT Quality Improvement and Clinical Care Committee. The survey collected data regarding center demographics, IS practices, and treatment of acute cellular rejection. RESULTS: Twenty-eight (64%) SPLIT centers responded with 22 (79%) centers performing more than 10 transplants per year and 17 (61%) following more than 100 post-transplant recipients. All centers use a written protocol, and 25 (89%) have a dedicated transplant pharmacist/PharmD. Twenty-five (89%) centers use steroids for induction alone or in combination with thymoglobulin/interleukin-2 antibodies. All centers use tacrolimus for initial maintenance therapy. Most centers have specialized protocols for ABO-incompatible transplants, recipients with renal dysfunction, autoimmune liver diseases, and liver tumors. Treatment of rejection varied but was associated with escalation in IS. CONCLUSION: IS practices among pediatric liver transplant centers are similar including the use of written protocols, pharmacy involvement, steroids for induction, tacrolimus as initial IS, tacrolimus reduction/delay for renal dysfunction, and escalation of IS with rejection severity. However, other IS practices show wide variability including treatment for ABO-incompatible grafts and presumed rejection. This study serves as a foundation to guide prospective research linking IS practice to outcomes to determine best practice.

A novel escalation from veno-venous bypass to veno-venous ECMO during orthotopic liver transplantation. A case report.

We describe the challenging perioperative course of a 55-year-old patient with hepatic failure requiring liver transplantation (LT). Different modalities of the extracorporeal device were successfully used, ranging from veno-veno bypass to partial and full veno-veno extracorporeal membrane oxygenation (ECMO) in order to optimize preload, reduce bleeding from the collateral circulation, optimize acid base balance and/or improve oxygenation. The case highlights the potential use of the device as a rescue method in challenging cases. Furthermore this is the first documented case that extracorporeal CO2 removal (ECCO2R) is used to optimize the biochemistry profile intraoperatively during a LT. The patient was weaned off the device at the end of the case and has been discharged home.

Staged biliary reconstruction after liver transplantation: A novel surgical strategy for high acuity pediatric transplant recipients.

INTRODUCTION: Biliary complications after pediatric orthotopic liver transplantation remain causes of significant patient morbidity. Staged operative approach in complex hepatobiliary surgery has improved postoperative outcomes but has not been evaluated in pediatric orthotopic liver transplantation. We sought to analyze the outcomes of staged biliary reconstruction after orthotopic liver transplantation in high acuity patients. METHODS: A retrospective analysis of 43 pediatric orthotopic liver transplantations at our center (January 2013 through December 2017). Median follow-up was 25 months. Variables were compared for group I: 1-stage orthotopic liver transplantation with biliary anastomosis (n = 6) versus group II: staged biliary reconstruction orthotopic liver transplantation (n = 37). RESULTS: Comparing groups I and II, median age (7.3 vs 4.8 years), weight (27 vs 19 kg), proportion of urgent orthotopic liver transplantation (50% vs 65%), partial graft orthotopic liver transplantation (33% vs 35%), and intraoperative red blood cell transfusion volume (11 vs 21 mL/kg) were comparable. Roux-en-Y hepaticojejunostomy was performed in 67% (group I) and 49% (group II). There was no biliary complication in both groups. For groups I and II, 3-year survival rates for graft (100% vs 92%, P = .477) and patient (100% vs 97%, P = .679) were comparable. CONCLUSION: Our study showed excellent outcomes with staged biliary reconstruction orthotopic liver transplantation in high acuity pediatric transplant recipients. This is the first report showing clinical applicability of staged biliary reconstruction orthotopic liver transplantation in children.

Impending total airway collapse involving a maxillary removable partial denture: A clinical report.

This article presents a rare incident of a bilateral maxillary removable partial denture as an airway foreign body. The removable partial denture and the surrounding soft tissue irritation caused partial obstruction of the airway. Impending airway collapse was avoided after successful removal of the foreign body. Removing a removable dental prostheses at night, not only to prevent soft tissue pathology but also to avoid ingestion or aspiration of the prosthesis, must be emphasized.

Perioperative anticoagulation practices for pediatric liver transplantation.

Despite continued advancements in perioperative care for pediatric liver transplant (LT), graft-threatening vascular occlusion events including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) remain a source of significant morbidity and mortality. Perioperative anticoagulation is commonly used for the prevention of HAT and PVT, but evidence-based guidelines are lacking. The goals of this survey were to determine the frequency of use of an anticoagulation protocol and to describe variation in anticoagulation practices among pediatric LT centers. The study consisted of an online survey distributed to members of SPLIT. The survey focused on institutional anticoagulation practices employed to reduce the incidence of graft and life-threatening vascular occlusion events. Responses were received from 31 of 39 SPLIT centers. All respondents report using anticoagulation after pediatric LT, and approximately 90% have institutional anticoagulation protocols. Subgroup analysis of high volume pediatric LT centers revealed similar variability in anticoagulation patterns. All participating SPLIT centers reported the use of post-transplant anticoagulation and nearly all use a protocol. However, there is marked variability in the type and dose of anticoagulation as well as the timing of initiation and duration of therapy across centers.

Monitoring for Nonoperating Room Anesthesia.

Procedures requiring nonoperating room anesthesia (NORA) continue to increase in quantity and complexity. The roles of anesthesiologists as members of care teams in nonoperating room locations continue to evolve. The safe provision of NORA requires strict adherence to standardized monitoring guidelines including pulse oximetry, capnography, electrocardiogram, and noninvasive blood pressure ampliflier. Body temperature should also be measured in appropriate scenarios. High-risk anesthetics require advanced preparation and monitoring.