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Mian MUM, Kennedy CE, Coss-Bu JA, Javaid R, Naeem B, Lam FW, Fogarty T, Arikan AA, Nguyen TC, Bashir D, Virk M, Harpavat S, Galvan NTN, Rana AA, Goss JA, Leung DH, Desai MS. Estimating risk of prolonged mechanical ventilation after liver transplantation in children: PROVE-ALT score. Pediatr Transplant 2024; 28:e14623. [PMID: 37837221 DOI: 10.1111/petr.14623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 07/11/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Children at high risk for prolonged mechanical ventilation (PMV) after liver transplantation (LT) need to be identified early to optimize pulmonary support, allocate resources, and improve surgical outcomes. We aimed to develop and validate a metric that can estimate risk for Prolonged Ventilation After LT (PROVE-ALT). METHODS We identified preoperative risk factors for PMV by univariable analysis in a retrospective cohort of pediatric LT recipients between 2011 and 2017 (n = 205; derivation cohort). We created the PROVE-ALT score by mapping multivariable logistic regression coefficients as integers, with cutoff values using the Youden Index. We validated the score by C-statistic in a retrospectively collected separate cohort of pediatric LT recipients between 2018 and 2021 (n = 133, validation cohort). RESULTS Among total 338 patients, 21% (n = 72) were infants; 49% (n = 167) had cirrhosis; 8% (n = 27) required continuous renal replacement therapy (CRRT); and 32% (n = 111) required management in hospital (MIH) before LT. Incidence of PMV post-LT was 20% (n = 69) and 3% (n = 12) required tracheostomy. Independent risk factors (OR [95% CI]) for PMV were cirrhosis (3.8 [1-14], p = .04); age <1-year (8.2 [2-30], p = .001); need for preoperative CRRT (6.3 [1.2-32], p = .02); and MIH before LT (12.4 [2.1-71], p = .004). PROVE-ALT score ≥8 [Range = 0-21] accurately predicted PMV in the validation cohort with 73% sensitivity and 80% specificity (AUC: 0.81; 95% CI: 0.71-0.91). CONCLUSION PROVE-ALT can predict PMV after pediatric LT with a high degree of sensitivity and specificity. Once externally validated in other centers, PROVE-ALT will empower clinicians to plan patient-specific ventilation strategies, provide parental anticipatory guidance, and optimize hospital resources.
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Affiliation(s)
- Muhammad Umair M Mian
- Division of Child Health, University of Missouri School of Medicine, Springfield Clinical Campus, Columbia, Missouri, USA
| | - Curtis E Kennedy
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jorge A Coss-Bu
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ramsha Javaid
- Division of Child Health, University of Missouri School of Medicine, Springfield Clinical Campus, Columbia, Missouri, USA
| | - Buria Naeem
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Fong Wilson Lam
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas Fogarty
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Ayse A Arikan
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Trung C Nguyen
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Dalia Bashir
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Manpreet Virk
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Sanjiv Harpavat
- Department of Pediatrics, Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Nhu Thao Nguyen Galvan
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Abbas A Rana
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - John A Goss
- Department of Surgery, Division of Abdominal Transplantation and Hepatobiliary Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel H Leung
- Department of Pediatrics, Division of Gastroenterology, Baylor College of Medicine, Houston, Texas, USA
| | - Moreshwar S Desai
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, USA
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Scalise PN, Koo DC, Staffa SJ, Cuenca AG, Kovatsis PG, Kim HB, Lee EJ. Immediate extubation after pediatric liver transplantation: Update on a single-center experience. Pediatr Transplant 2024; 28:e14669. [PMID: 38059422 DOI: 10.1111/petr.14669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/27/2023] [Accepted: 11/15/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE Immediate extubation (IE) following liver transplantation (LT) is increasingly common in adult patients. This study reviews our center's experience with IE in children following LT to determine characteristics predictive of successful IE and its effects on post-operative outcomes. METHODS We performed a retrospective chart review of all patients who underwent LT at our institution between January 2005 and November 2022. Patients with concomitant lung transplants and chronic ventilator requirements were excluded. RESULTS Overall, 235 patients met study criteria. IE was achieved in 164 (69.8%) patients across all diagnoses and graft types. Of IE patients, only two required re-intubation within 3 days post-transplant. IE patients exhibited significantly shorter ICU (2 [1, 3 IQR] vs. 4 [2, 4 IQR] days, p < .001) and hospital lengths of stay (17 [12, 24 IQR] vs. 22 [14, 42 IQR] days, p = .001). Pre-transplant ICU requirement, high PELD/MELD score, intraoperative transfusion, cold ischemia time, and pressor requirements were risk factors against IE. There was no association between IE and recipient age or weight. The proportion of patients undergoing IE post-transplant increased significantly over time from 2005 to 2022 (p < .001), underscoring the role of clinical experience and transplant team learning curve. CONCLUSION Spanning 18 years and 235 patients, we report the largest cohort of children undergoing IE following LT. Our findings support that IE is safe across ages and clinical scenarios. As our center gained experience, the rate of IE increased from 40% to 83%. These trends were associated with lower ICU and LOS, the benefits of which include earlier patient mobility and improved resource utilization.
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Affiliation(s)
- P Nina Scalise
- Department of Surgery, Harvard Medical School, Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Donna C Koo
- Department of Surgery, Harvard Medical School, Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alex G Cuenca
- Department of Surgery, Harvard Medical School, Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Heung Bae Kim
- Department of Surgery, Harvard Medical School, Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eliza J Lee
- Department of Surgery, Harvard Medical School, Pediatric Transplant Center, Boston Children's Hospital, Boston, Massachusetts, USA
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Baba C, Ninagawa J, Uranaka M, Hashiya M, Sakamoto S, Kasahara M, Suzuki Y, Nagasaka Y, Kasuya S. Criteria for immediate extubation after pediatric liver transplantation in a single pediatric liver transplant center in Japan. Clin Transplant 2024; 38:e15188. [PMID: 37937361 DOI: 10.1111/ctr.15188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/09/2023]
Abstract
Immediate extubation (IE) following liver transplantation (LT) has become the standard practice, even for pediatric patients. However, no preoperative or postoperative case selection protocols for IE are currently available. We have developed selection criteria for IE following pediatric LT. The aim of this study is to assess the safety and effectiveness of these selection criteria and anesthetic management protocol implemented in our hospital for IE after pediatric LT. METHOD This was a retrospective study. The records of all cases undergoing LT in our center from January 2016 to December 2020 were collected. We excluded cases > 18 years old at the time of LT. Enrolled cases were divided into two groups: cases with immediate extubation (IE) or without immediate extubation (NIE). We compared preoperative conditions, intraoperative management, and postoperative courses. Finally, we classified NIE group patients into cases extubated at postoperative day 1 (early; E-NIE) and others (delayed; D-NIE) and compared their underlying diseases and postoperative courses. RESULTS In the IE group, there were 81 cases, while the NIE group consisted of 185 cases. All patients in the IE group were successfully extubated without any instances of re-intubation due to respiratory failure. Within the E-NIE group, comprising 130 cases, all patients were ultimately extubated without the need for tracheostomy. However, in the D-NIE group, which encompassed 53 cases, seven patients required tracheostomy. CONCLUSION In our center, the implementation of our anesthesia management protocol and the use of pre/postoperative case selection criteria have allowed for the safe practice of IE following pediatric LT. However, it should be noted that patients who cannot be extubated by Postoperative Day 1 (POD1) may be at an increased risk of requiring a tracheostomy. When contemplating IE, it is crucial to take into account the disease-specific physiological aspects and surgical site situations.
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Affiliation(s)
- Chiaki Baba
- Division of Anesthesia, Department of Anesthesia and Critical Care, National Center for Child Health and Development, Tokyo, Japan
- Department of Anesthesia, Tokyo Women's Medical University, School of Medicine, Tokyo, Japan
| | - Jun Ninagawa
- Division of Anesthesia, Department of Anesthesia and Critical Care, National Center for Child Health and Development, Tokyo, Japan
| | - Makoto Uranaka
- Division of Anesthesia, Department of Anesthesia and Critical Care, National Center for Child Health and Development, Tokyo, Japan
| | - Mai Hashiya
- Division of Anesthesia, Department of Anesthesia and Critical Care, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Center for Organ Transplantation, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Center for Organ Transplantation, National Center for Child Health and Development, Tokyo, Japan
| | - Yasuyuki Suzuki
- Division of Anesthesia, Department of Anesthesia and Critical Care, National Center for Child Health and Development, Tokyo, Japan
- Department of Anesthesia, Tokyo Women's Medical University, School of Medicine, Tokyo, Japan
| | - Yasuko Nagasaka
- Department of Anesthesia, Tokyo Women's Medical University, School of Medicine, Tokyo, Japan
| | - Shugo Kasuya
- Division of Anesthesia, Department of Anesthesia and Critical Care, National Center for Child Health and Development, Tokyo, Japan
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The Development of an Enhanced Recovery Protocol for Kasai Portoenterostomy. CHILDREN 2022; 9:children9111675. [DOI: 10.3390/children9111675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Balancing post-operative adequate pain control, respiratory depression, and return of bowel function can be particularly challenging in infants receiving the Kasai procedure (hepatoportoenterostomy). We performed a retrospective chart review of all patients who underwent the Kasai procedure from a single surgeon at Children’s Healthcare of Atlanta from 1 January 2018, to 1 September 2022. 12 patients received the Kasai procedure within the study period. Average weight was 4.47 kg and average age was 7.4 weeks. Most patients received multimodal pain management including dexmedetomidine and/or ketorolac along with intravenous opioids. A balance of colloid and crystalloids were used for all patients; 57% received blood products as well. All patients were extubated in the OR and transferred to the general surgical floor without complications. Return of bowel function occurred in all patients by POD2, and enteral feeds were started by POD3. One patient had a presumed opioid overdose while admitted requiring a rapid response and brief oxygen supplementation. Simultaneously optimizing pain control, respiratory safety, and bowel function is possible in infants receiving the Kasai procedure. Based on our experience and the current pediatric literature, we propose an enhanced recovery protocol to improve patient outcomes in this fragile population. Larger, prospective studies implementing an enhanced recovery protocol in the Kasai population are required for stronger evidence and recommendations.
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