Trends in transfusion practice over 20 years in paediatric liver transplant programme

A Case of Difficult Arterial Cannulation: Is Intra-Arterial Blood Pressure Monitoring an Absolute Requirement for Paediatric Liver Transplantation?

Invasive arterial blood pressure monitoring is the standard of practice in terms of intraoperative blood pressure surveillance during liver transplantation. While this is an ideal, achieving reliable arterial access can be extremely challenging in the paediatric and neonatal population, repeated attempts at arterial cannulation are not without risk and alternative best practice means of haemodynamic monitoring are not clearly established. We describe a case of paediatric liver transplantation in a 3.9 kg infant that was complicated by difficult arterial cannulation, and we suggest that, when reasonable attempts to achieve intra-arterial access have failed, it is safe to proceed with paediatric liver transplantation with non-invasive blood pressure monitoring at 2 min intervals throughout the case and 1 min intervals at reperfusion. We recognise the unique technical challenges in paediatric liver transplant anaesthesia, and we advocate for the establishment of formal clinical training competencies in line with adult practice recommendations. We recommend the use of the Seldinger technique under ultrasound guidance as a first-line approach when difficult arterial cannulation is anticipated, and we discuss techniques for alternative approaches. We suggest that additional alternative means of haemodynamic monitoring should be considered when arterial access cannot be established; however, as no method demonstrates absolute superiority, one or a combination of techniques should be considered, depending on local availability and expertise.

Pediatric non-red cell blood product transfusion practices: what's the evidence to guide transfusion of the 'yellow' blood products?

PURPOSE OF REVIEW

Research studies pertaining to the management of pediatric non-red cell blood product transfusion is limited. Clinical practices vary within disciplines and regions. Anesthesiologists need evidence-based guidelines to make appropriate and safe decisions regarding transfusion of the 'yellow' blood products for pediatric patients.

RECENT FINDINGS

This review outlines clinical indications for transfusion of fresh frozen plasma, cryoprecipitate, platelets, and fibrinogen concentrate in pediatrics. Recent studies of non-red blood cell transfusions in critical, but stable situations are highlighted. Recommendations to guide transfusion of the 'yellow' blood products in operative and non-operative settings are summarized. Special attention is drawn to guidelines in massive hemorrhage and trauma situations.

SUMMARY

Evidence-based guidelines and expert consensus recommendations exist to guide the transfusion of pediatric non-red blood products and should be followed when transfusing the 'yellow' blood components. As high-quality studies in neonates, infants and children are limited, future research should broaden our knowledge in this direction with the goal to use restrictive strategies to improve patient outcomes.