Predictors of Immediate Tracheal Extubation in the Operating Room After Pediatric Liver Transplantation.

OBJECTIVES: Pediatric orthotopic liver transplant recipients frequently need mechanical ventilation during the immediate posttransplant period. However, intensive care unit beds are costly and scarce; therefore, anticipating which patients will require postoperative mechanical ventilation support is important. In addition, immediate postoperative extubation may reduce the incidence of postoperative respiratory complications and improve patient outcomes after orthotopic liver transplant. Here, we aimed to determine the predictors of need for mechanical ventilation after orthotopic liver transplant in pediatric patients. MATERIALS AND METHODS: We retrospectively analyzed the records of 57 pediatric patients who underwent orthotopic liver transplant (performed by the same team at Baskent University Hospital from April 1996 to August 2009). Patients were divided into 2 groups according to whether they required postoperative mechanical ventilation or not. Collected data included demographic features; comorbidities; cause of liver failure; perioperative laboratory values; intraoperative hemodynamic parameters; use and volume of crystalloids, colloids, and blood products; albumin levels; portal vein clamping time, requirement of inotropes/vasopressors; and anesthesia duration. RESULTS: Mean age and body weight of patients were 25.0 ± 23.1 months and 10.8 ± 5.3 kg, respectively. Of 57 patients, 26 (46%) needed postoperative mechanical ventilation. Compared with those who did not require postoperative mechanical ventilation, patients who required mechanical ventilation had growth failure (P = .03), higher mean intraoperative lactate level (P = .03), and higher mean intraoperative fresh frozen plasma/erythrocyte suspension (P = .049) and intraoperative vasopressor (P = .022) requirements. Multivariate logistic regression analysis revealed that growth failure (odds ratio = 37; P = .03) and higher intraoperative lactate level (odds ratio = 1.5; P = .03) were predictors of the need for mechanical ventilation. CONCLUSIONS: About 46% of our pediatric orthotopic liver transplant recipients required mechanical ventilation postoperatively. Growth failure and higher intraoperative lactate levels were associated with need for postoperative mechanical ventilation.

Ultrasound-Guided Popliteal Sciatic Block Provides Adequate Analgesia During Urgent Endovascular Treatment of Critical Limb Ischemia with Resting Pain.

PURPOSE: To demonstrate feasibility and safety of ultrasound-guided popliteal sciatic nerve block for providing analgesia during urgent endovascular treatment of critical limb ischemia with resting pain. MATERIALS AND METHODS: Ultrasound-guided popliteal sciatic blocks were performed by an interventional radiologist in angiography suite immediately prior to commencement of urgent endovascular treatment of 30 critical limb ischemia patients. Subjective pain levels prior to and following sciatic block were assessed using the visual analog scale (VAS). Need for any supplemental anxiolytics or analgesics during treatment was recorded. Post-procedural evaluation of patient and operator satisfaction levels regarding the intervention was also documented. RESULTS: Ultrasound-guided sciatic block provided adequate analgesia in all patients; VAS scores were 0 (no pain) in 87% and 1-3 (mild to annoying pain) in 13%. Two patients required anxiolytic premedication. Additional analgesia was not required during course of endovascular treatment of any patients. Time necessary to perform sciatic block ranged 3-9 (mean 5.9 ± 1.3) min. Median number of needle attempts was 1 (range 1-3). Onset of satisfactory block ranged from 5 to 20 min (mean 9.4 ± 2.6 min). Mean treatment time was 102.2 ± 36.7 min, and balloon time was 22.4 ± 6.1 min. Patient and operator satisfaction with pain control were very good in all cases. There were no procedure-related complications. CONCLUSIONS: Ultrasound-guided popliteal sciatic block is a feasible and safe alternative for providing adequate analgesia during urgent endovascular treatment of critical limb ischemia with resting pain. LEVEL OF EVIDENCE: Level 4, case series.

Incidence and risk factors of intraoperative adverse events during donor lobectomy for living-donor liver transplantation: a retrospective analysis.

OBJECTIVES: To evaluate the frequency, type, and predictors of intraoperative adverse events during donor hepatectomy for living-donor liver transplant. MATERIALS AND METHODS: Retrospective analyses of the data from 182 consecutive living-donor liver transplant donors between May 2002 and September 2008. RESULTS: Ninety-one patients (50%) had at least 1 intraoperative adverse event including hypothermia (39%), hypotension (26%), need for transfusions (17%), and hypertension (7%). Patients with an adverse event were older (P = .001), had a larger graft weight (P = .023), more frequently underwent a right hepatectomy (P = .019), and were more frequently classified as American Society of Anesthesiologists physical status class II (P = .027) than those who did not have these adverse events. Logistic regression analysis revealed that only age (95% confidence interval 1.018-1.099; P = .001) was a risk factor for intraoperative adverse events. Patients with these adverse events more frequently required admission to the intensive care unit and were hospitalized longer postoperatively. A before and after analysis showed that after introduction of in-line fluid warmers and more frequent use of acute normovolemic hemodilution, the frequency of intraoperative adverse events was significantly lower (80% vs 29%; P < .001). CONCLUSIONS: Intraoperative adverse events such as hypothermia and hypotension were common in living-donor liver transplant donors, and older age was associated with an increased risk of these adverse events. However, the effect of these adverse events on postoperative recovery is not clear.

Percutaneous dilational tracheotomy for airway management in a newborn with Pierre-Robin syndrome and a glossopharyngeal web.

Pierre-Robin syndrome (PRS) is often associated with difficulty in endotracheal intubation. We present the use of percutaneous dilational tracheotomy (PDT) for airway management of a newborn with PRS and a glossopharyngeal web. A 2-day-old term newborn with PRS and severe obstructive dyspnea was evaluated by the anesthesiology team for airway management. A direct laryngoscopy revealed a glossopharyngeal web extending from the base of the tongue to the posterior pharyngeal wall. The infant was spontaneously breathing through a 2 mm diameter fistula in the center of this web. It was decided that endotracheal intubation was impossible, and a PDT was planned. The trachea of the newborn was cannulated, using a 20 gauge peripheral venous catheter and a 0.71 mm guide wire was introduced through this catheter. Using 5 French, 7 French, 9 French, and 11 French central venous catheter kit dilators, staged tracheotomy stoma dilation was performed. By inserting a size 3.0 tracheotomy cannula, PDT was successfully completed in this newborn. This case describes the successful use of PDT for emergency airway management of a newborn with PRS and glossopharyngeal web.