Living related liver transplantation in infants and children: report of anesthetic care and early postoperative morbidity and mortality.

STUDY OBJECTIVE: To determine those infants at high risk for perioperative complications and mortality following living, related liver transplantation. DESIGN: Retrospective chart review. SETTING: Large metropolitan teaching hospital. MEASUREMENTS AND MAIN RESULTS: The charts and anesthetic records of the 12 infants and children who received the left lateral hepatic segment from a living relative the past 2 years at our institution were reviewed. The records were examined to determine the causes of perioperative morbidity and to identify patients at high risk for serious complications and mortality. All infants and children (mean +/- SD age, 29+/-30 months; weight, 13.6 +/-6.8 kg) survived the operation (8.3+/-1.7 hours) without intraoperative complications. The average blood loss, including 500 mL of recipient blood used to flush the liver before reperfusion, was 1483 +/-873 mL (119+/-70 mL/kg). Three infants developed portal vein thrombosis, and one of these infants also had hepatic artery thrombosis. The risk of vessel thrombosis was significantly higher (3/3 vs. 0/9; p<0.0045) in infants less than 9 kg body weight, as was the risk of death (2/3 vs. 0/9; p<0.045). Both children who died had vascular thrombosis. Other serious complications were bleeding, 6; infection, 7; acute rejection, 3; and bile leak, 2. CONCLUSIONS: Infants and children can successfully undergo living, related liver transplantation. However, the risks of vascular complications and death are greater in infants less than 9 kg body weight.

Living liver donor surgery: report of initial anesthesia experience.

The charts and anesthetic records of 12 patients who donated the left lateral segment of their liver to a related infant or child to treat liver failure were retrospectively reviewed. Blood loss, need for transfusion, fluids administered, surgical length, and perioperative complications were investigated. The records also were examined to determine the hemodynamic stability of patients undergoing donor hepatectomy to assess their need for invasive monitoring. There were no episodes of hypotension or hemodynamic instability. The average operating time was 9.6 +/- 1.1 hours. The blood loss was 562 +/- 244 mL (range 300 to 1100 mL). Four patients received their own cell saver blood (200 mL, 220 mL, 300 mL, 475 mL), and one patient received 1 U (350 mL) of predonated autologous blood. The average hemoglobin decreased significantly (p = 0.001) from a preoperative value of 14.1 +/- 1.2 to 12.3 +/- 1.8 g/dL in the recovery room. All patients were extubated in the operating room or recovery room. Patients were discharged home in 6.9 +/- 1.3 days (range 5 to 9 days). Living-related liver resection can be performed with noninvasive monitoring and without the need for heterologous blood products.

Trained nurses can provide safe and effective sedation for MRI in pediatric patients.

PURPOSE: To determine the success rate, safety and complications using a standard protocol and trained nurses to provide sedation for MRI under the supervision of a radiologist. MATERIALS AND METHODS: Nurses were trained to provide sedation via a standard protocol for pediatric patients undergoing diagnostic MRI. Oral chloral hydrate (80-100 mg x kg(-1)) was used for children less than 18 mo of age. Older children received either 1-6 mg x kg(-1) pentobarbital i.v., with or without 1-2 microg x kg x hr(-1) fentanyl, or 25 mg x kg(-1) thiopental pr. Sedation was defined as successful if it allowed completion of the MRI without image distorting patient movement. The records of 572 MRIs performed on 488 pediatric patients (mean age 5+/-4 yr; age 2 mo-14 yr) from 1991 to July 1995 were reviewed to determine the success rate and complications using the sedation program. RESULTS: Most, 91.8% (525/572), of the MRIs were successfully completed in 445 patients. The reasons for failure were inadequate sedation (45, 95.7%) and coughing (2, 4.2%). The failure rate was much higher before 1994 (38/272, 14%) than after (9/300, 3%; P<0.0001). Failure was more common if rectal thiopental was used (23/172, 14%) than intravenous pentobarbital (19/256, 7.4%; P<0.05). The failure rate was also high in patients with a history of a behavioural disorder (10/59, 17%). There were no deaths or unexpected admissions as a result of the sedation program. CONCLUSION: A high success rate can be achieved as experience is gained using a standard protocol and trained nurses to sedate children for MRI.

Perioperative anesthetic management of the kidney-pancreas transplant recipient.

Patients undergoing simultaneous pancreas-kidney transplantation are at risk for a variety of serious perioperative complications. These are related to the chronic and acute problems associated with end-stage renal disease and insulin-dependent diabetes mellitus and the prolonged, vascular and ductal surgery required to implant the two allografts. A number of strategies need to be integrated and diligently implemented to minimize the physiologic perturbations and complications related to the recipient's comorbid conditions and revascularization of the allografts. A major objective of the perioperative anesthetic management of simultaneous pancreas-kidney transplantation is to maximize cardiovascular performance in a way that provides optimum graft perfusion and recovery, while avoiding myocardial ischemia. Adherence to this objective, along with very effective immunosuppressants, surgical refinements, meticulous anesthetic preparation, extensive and frequent physiologic and metabolic monitoring, and quick response to abnormal findings has resulted in remarkably low recipient morbidity and mortality, and very high graft survival rates.

Hemodynamic and metabolic manifestations of acute endotoxin infusion in pigs with and without the malignant hyperthermia mutation.

BACKGROUND: The hypermetabolic state induced by acute endotoxemia and malignant hyperthermia (MH) may be indistinguishable. The aims of this study were (1) to investigate the differences between MH and sepsis, (2) to determine whether acute endotoxemia can trigger MH, and (3) to establish the effects of dantrolene in these two disorders. METHODS: Three groups of swine were studied. All pigs were invasively monitored and initially anesthetized with nontriggering agents. A placebo MH-susceptible group (n = 5) received normal saline whereas the endotoxin groups (MH-susceptible, n = 6; MH-negative, n = 4) received intravenous endotoxin (250 microg/kg total) during 2.5 h. Halothane (1.5%) and succinylcholine (2-4 mg/kg) were then administered, followed by two doses of dantrolene (4 mg/kg total). RESULTS: Endotoxin infusion resulted in pulmonary hypertension and systemic hypotension in pigs with and without the MH mutation, but did not trigger MH. Halothane and succinylcholine triggered MH, evidenced by a markedly higher oxygen consumption in the MH-susceptible pigs that received endotoxin (325+/-196 ml/min) and those that did not (374+/-110 ml/min) compared to the MH-negative pigs (69+/-15 ml/min, P<0.0009), as well as muscular rigidity in the susceptible animals. Dantrolene reversed these changes. Three of the six MH-susceptible pigs that received endotoxin died; two died soon after triggering and one after dantrolene administration. In contrast, none of the MH-negative pigs or the MH-susceptible pigs that did not receive endotoxin died (0 of 9 vs. 3 of 6, P = 0.044). CONCLUSION: Endotoxemia does not trigger MH, but may worsen outcome if it occurs.

Carbon dioxide embolism during laparoscopy: effect of insufflation pressure in pigs.

Carbon dioxide embolism is a rare but potentially devastating complication of laparoscopy. To determine the effects of insufflation pressure on the mortality from carbon dioxide embolism, six swine had intravascular insufflation with carbon dioxide for 30 seconds using a Karl Storz insufflator at a flow rate of 35 mL/kg/min. The initial insufflation pressure was 15 mm Hg. Following recovery from the first embolism, intravascular insufflation using a pressure of 20 mm Hg at the same flow rate was performed in the surviving animals. Significantly less carbon dioxide (8.3 +/- 2.7 versus 16.7 +/- 3.9 mL/kg; p < 0.02) was insufflated intravascularly at 15 mm Hg than at 20 mm Hg pressure. All of the pigs insufflated at 15 mm Hg pressure with a flow rate of 35 mL/kg/min survived. In contrast, 4 of the 5 pigs insufflated at 20 mm Hg pressure died. The surviving pig died when insufflated with 25 mm Hg pressure following an embolism of 15.7 mL/kg. Intravascular injection was often associated with an initial rise in end-tidal carbon dioxide tension, followed by a rapid fall in all cases where the embolism proved fatal. Insufflation should be begun with a low pressure and a slow flow rate to limit the volume of gas embolized in the event of inadvertent venous cannulation. Insufflation should immediately be stopped if a sudden change in end-tidal carbon dioxide tension occurs.

Differential diagnosis of thyroid crisis and malignant hyperthermia in an anesthetized porcine model.

The intra-operative differential diagnosis between thyroid crisis and malignant hyperthermia can be difficult. Also stress alone can trigger MH. The purposes of this study were: 1) to investigate the metabolic and hemodynamic differences between thyroid crisis and MH, 2) determine how thyroid crisis affects the development of MH, and 3) determine if the stress of thyroid crisis can trigger MH in susceptible individuals. We studied MH susceptible and normal swine. Two groups of animals (MH susceptible and normal) were induced into thyroid crisis (critical core hyperthermia, sustained tachycardia and increase in oxygen consumption) by pretreatment with intraperitoneal triiodothyronine (T3) followed by large hourly intravenous injections of T3. Two similar groups were given intravenous T3 but no pretreatment. These animals did not develop thyroid crisis and served as controls. Thyroid crisis did not result in metabolic changes or rigidity characteristic of an acute episode of MH. When the animals were subsequently challenged with MH triggering agents (halothane plus succinylcholine) dramatic manifestations of fulminant MH episodes (acute serious elevation in exhaled carbon dioxide, arterial CO2, rigidity and acidemia) were noted only in the MH susceptible animals. Although thyroid crisis did not trigger MH in the susceptible animals it did decrease the time to trigger MH (14.1 +/- 7.2 minutes versus 47.2 +/- 17.7 minutes, p < 0.01) in susceptible animals. Hormone induced elevations in temperature and possibly other unidentified factors during thyroid crisis may facilitate the triggering of MH following halothane and succinylcholine challenge.

Total pancreatectomy with islet cell autotransplantation: anesthetic implications.

STUDY OBJECTIVE: To make recommendations for the perioperative management of patients undergoing total pancreatectomy with islet cell autotransplantation. DESIGN: Retrospective review. SETTING: University hospital. PATIENTS: 41 patients undergoing total pancreatectomy with autologous islet cell transplantation for chronic pancreatitis from 1977 to 1996. INTERVENTIONS: The charts and anesthetic records were reviewed, specifically investigating the changes in portal venous pressure, blood pressure (BP), and central venous pressure with islet cell injection. The records also were examined for blood glucose levels, type of fluids administered, blood loss, and postoperative complications. MEASUREMENTS AND MAIN RESULTS: Injection of islet cells into the portal vein caused a significant increase in portal venous pressures (8.5 +/- 4.8 to 27 +/- 16 cm/H2O; p < 0.001), which remained elevated at the end of injection (23 +/- 12 cm/H2O; p < 0.001). Central venous pressures also increased a small amount (9.3 +/- 4.3 to 10.6 +/- 5.8 mmHg; p < 0.05). In contrast, systolic blood pressures (SBPs) fell with administration of the islet cells (110 +/- 15 to 103 +/- 17 mmHg; p < 0.01), but SBP recovered in most patients at the end of injection (106 +/- 16 mmHg; p = NS). However, 6 patients (14.6%) required vasopressors to maintain adequate BPs. Blood glucose levels were significantly higher immediately prior to islet cell infusion in patients who had received dextrose-containing solutions than those who did not (246 +/- 80 vs. 176 +/- 43 gm/dl; p = 0.002). Median blood loss was 2000 ml (range 350 to 12,000 ml), and most patients (95.1%) required blood transfusions. CONCLUSION: Although total pancreatectomy with islet cell autotransplantation is a difficult operation, with significant blood loss, most patients tolerate surgery and injection of islet cells into their portal system without hemodynamic instability. Glucose-containing solutions should not be administered to patients prior to islet cell infusion because hyperglycemia, which can damage islet cells, may result.

Double volume exchange transfusion for ABO incompatible liver transplantation in paediatric patients: intraoperative and preoperative approach.

Double volume blood exchange transfusions (DBVET) were used to reduce the serum antibody levels in six paediatric patients receiving ABO incompatible hepatic allografts. In four patients, the exchange transfusions took place on the ward prior to surgery. In three of these four patients who had titres measured, the anti-A IgM titres fell from 1024 to 64, 64 to 8, and 128 to 16, respectively. The anti-A IgG titres fell from 32 to 16 and 512 to 64 in two patients, but rose from 16 to 32 in the third. In two patients DBVET were performed intraoperatively using a rapid infusion device. The IgM titres fell from 256 to 32 and 64 to 1, respectively, and the IgG titres fell from 16 to 4 and 2 to 0. Intraoperative DBVET can acutely and effectively reduce blood group antibodies. Intraoperative DBVET may reduce graft ischaemia time and allow red blood cell salvage.

Comparison of the flow rates of central venous catheters designed for rapid transfusion in infants and small children.

Large-bore Hickman catheters are useful in infants and small children for the rapid transfusion of blood or fluids into the central circulation. Recently high-flow plastic sheaths have been developed for the same purpose. We compared the flow rates of normal saline, 5% albumin and packed red blood cells through two sizes of Hickman catheters that have been recommended for major surgery in infants to five sizes of Arrow plastic sheaths of comparable external diameters, and to 14 and 16 gauge Jelco catheters. The flow rates of all three solutions through the plastic sheaths and the 14 gauge Jelco catheters were superior to both sizes of Hickman catheters. Shortening the Hickman catheters improved their flow. High-flow plastic sheaths can provide a useful alternative to Hickman catheters in patients where permanent, large-bore central venous catheters are not required. Hickman catheters should be shortened as much as safely possible if massive haemorrhage is anticipated.

Anaesthetic management of bone marrow transplant recipients less than two years of age.

The charts and anaesthetic records of 97 infants less than two years of age who underwent bone marrow transplantation at the University of Minnesota from 1978-1992 were retrospectively reviewed. These infants underwent 564 general anaesthetics. There were 48 perioperative complications, most (39) involving the airway. There were 20 difficult intubations occurring in 13 patients. The causes of the difficult intubations were anatomical abnormalities (12), mucositis (4), pharyngeal oedema (3) and emesis upon induction of anaesthesia (1). Four intraoperative deaths occurred. The deaths were caused by haemorrhage (2), pulmonary embolism (1) and myocardial ischaemia (1). Four patients died within 72 h of surgery; one from cerebral oedema following an intraoperative cardiac arrest, one from fungal septicaemia, one from haemorrhage and one from multiple organ failure following an intracerebral haematoma. Infants undergoing bone marrow transplantation are at high risk for perioperative morbidity and mortality, particularly from complications involving the airway, bleeding or sepsis.

Hemodynamic, respiratory, and metabolic effects of laparoscopic cholecystectomy.

In 10 patients undergoing laparoscopic cholecystectomy, creation of pneumoperitoneum caused immediate venous hypertension and stasis in the lower extremities as measured by percutaneous catheter and duplex scanning. These changes disappeared after deflation. As measured by spirometry, significant reductions in forced vital capacity of 23% and forced expiratory volume in 1 second of 22% were present 24 hours after surgery, and plasma interleukin-6 levels rose to 18 pg/mL. The visual analogue scale of resting pain increased to a median value of 2.5 postoperatively. When compared with other studies of open cholecystectomy, our results showed fewer restrictions of ventilation, lower cytokine levels, and lower pain scores. The minimal soft tissue trauma and early ambulation after laparoscopic cholecystectomy may decrease the risk of thrombosis despite an acute episode of venous stasis.

Lower extremity hypothermia is beneficial during infra-renal aortic cross-clamping in pigs.

The effects of lower extremity hypothermia during aortic cross-clamping are unknown. To compare the effects of lower extremity hypothermia with normothermia during aortic cross-clamping, two groups of six (25-40 kg) anesthetized pigs had their aortas cross-clamped below the renal arteries for 2 h. The cold group had their lower extremities cooled during cross-clamping to a quadriceps muscle temperature of 28 degrees C by using convective cooling. The warm group had the quadriceps muscle temperature maintained at 38 degrees C with convective warming. Saline, 0.9%, was used to maintain the pulmonary capillary wedge pressures at 5 mm Hg in both groups. Reperfusion of the lower extremities resulted in a small but significant decrease in the blood temperature from 36.6 +/- 0.3 degrees C (mean +/- SE) to 35.6 +/- 0.3 degrees C 1 min after reperfusion in the cold group, but did not change the blood temperature in the warm group. Both the cardiac output and the lower extremity arterial flow were greater in the cold group at 1 and 5 min after cross-clamp release. Also one pig in the warm group required resuscitation with 1 mg of epinephrine intravenously to treat severe hypotension and myocardial depression after cross-clamp release. We conclude that hypothermia of the lower extremities may be beneficial for surgery involving aortic cross-clamping.

High levels of carbon monoxide are produced by electro-cautery of tissue during laparoscopic cholecystectomy.

Pyrolysis of tissue in a hypoxic environment can produce carbon monoxide. The atmosphere of the peritoneal cavity is rendered hypoxic during laparoscopic cholecystectomy by insufflation with 100% carbon dioxide. To determine whether carbon monoxide is produced by electrocautery of tissue during laparoscopic cholecystectomy, nine patients undergoing this procedure had the insufflation gas after use of electrocautery analyzed for carbon monoxide. Blood was analyzed for carboxyhemoglobin in these same patients to determine whether carbon monoxide was being absorbed in dangerous amounts. Carbon monoxide was present in the peritoneal cavity 5 min after use of electrocautery was initiated at a median concentration of 345 ppm (range 25-1600 ppm), and at the end of surgery at a concentration of 475 ppm (range 100-1900 ppm). This was well in excess of the 35 ppm upper limit for a 1-h exposure set by the Environmental Protection Agency. The carboxyhemoglobin concentrations (mean +/- SD) were the same at the beginning (1.3% +/- 0.7%), end (1.2% +/- 0.7%), and the day after surgery (1.1% +/- 0.6%). Although there was no evidence of significant absorption of carbon monoxide in these patients, care should be taken to scavenge the gases produced by cautery of tissues to avoid operating room contamination during laparoscopic surgery.