Early detection of the graft failure after pediatric liver transplantation: a Bergamo experience

BACKGROUND

Effective indicators of the early graft failure after pediatric liver transplantation are currently a crucial question. The aim of this study was to analyze retrospectively laboratory parameters that may help anticipate an early graft loss (GL).

METHODS

The 131 pediatric liver transplantations, performed in our hospital from January 2002 to December 2005, were reviewed. Post-operative laboratory parameters, collected in the first 36 h of the Paediatric Intensive Care Unit (PICU) stay, were analyzed for children with both graft survival and GL. Receiver operating characteristics analysis was used to identify the optimal cut-off for the laboratory parameters. Multivariate logistic regression analysis was used to calculate the adjusted risk of GL for the prognostic parameters identified.

RESULTS

The mean age at transplant was 1.1 years. The two groups were comparable for all recipient and donor variables considered. Children with GL showed significantly higher levels of ammonia and transaminase at the admission to the PICU and higher levels of prothrombin time, creatinine, lactate and a lower level of platelets at the 36 h of PICU. The laboratory parameters over the cut-off value by the multivariate logistic regression identified all early thromboses earlier than Doppler ultrasound.

CONCLUSIONS

This study suggests that routine blood tests may help to anticipate an early loss of liver grafts in children after transplantation and may improve our diagnostic investigation in the case of thrombosis suspicion. Further validation by a prospective study is needed to carefully assess the sensitivity and specificity of the identified criteria.

Randomized controlled trial of duration of analgesia following intravenous or rectal acetaminophen after adenotonsillectomy in children

BACKGROUND

Doses of acetaminophen 40 mg kg(-1) rectally and 15 mg kg(-1) i.v. produce similar effect-site concentrations. However, the clinical effectiveness of these routes has not been compared. The aim of this study was to compare duration and efficacy of analgesia in children following adenotonsillectomy after acetaminophen either 40 mg kg(-1) rectally or 15 mg kg(-1) i.v.

METHODS

Fifty children aged between 2 and 5 yr were recruited. They received a standardized anaesthetic, including 2 microg kg(-1) of fentanyl. Children were randomized to receive either rectal or i.v. acetaminophen. Postoperative pain was assessed regularly with the Children and Infants Postoperative Pain Scale score and rescue analgesia provided if scores were 4 or greater. The primary outcome measure was time to first analgesia. Results were plotted with a Kaplan-Meier analysis and median time to rescue analgesia compared between the groups.

RESULTS

The protocol was successfully completed in 46 children. Forty-five children required rescue medication. The time to first rescue analgesia was longer in children receiving rectal acetaminophen (median 10 h, inter-quartile range 9-11 h) compared with those receiving i.v. acetaminophen (7, 6-10 h) with a P-value of 0.01 by log-rank test for equality in survivor function. Few children in either group required rescue analgesia within the first 6 h with differences between the groups being most prominent in the period from 6 to 10 h.

CONCLUSIONS

Rectal acetaminophen 40 mg kg(-1) provides longer analgesia for moderately painful procedures when compared with 15 mg kg(-1) acetaminophen i.v.

Postoperative Sedation and Analgesia After Pediatric Liver Transplantation

The goal of sedation in the pediatric intensive care unit (PICU) is to produce a calm and comfortable child, free from pain and discomfort. Children receiving liver transplantation need analgesics to control pain from surgical incisions, drains, vascular access, or endotracheal suctioning. Sedatives are used to facilitate the delivery of nursing care, to prevent self-extubation, and to facilitate mechanical ventilation. Optimal sedation produces a state in which the patient is somnolent, responsive to the environment but untroubled by it, and with no excessive movements. A common problem in the PICU is the fluctuation in the delivery of sedatives and analgesics depending on the health care providers and on a breakdown in communication between physicians and nurses to define end points for pharmacological therapy. This variability more often leads to oversedation rather than undersedation. Oversedation delays extubation, promotes ventilator-associated pneumonia, and increases the risk of reintubation. The use of written sedation policies to guide practice at the bedside reduces the length of time for which patients require mechanical ventilation and the length of PICU stay. Protocols for drug administration practices increase patient safety during mechanical ventilation, promote nursing autonomy, and facilitate communication between nurses and physicians as well as between nurses.