Transfusion-sparing anesthetic management and immediate extubation in pediatric liver transplantation

Abstract

Abstract Background Blood-sparing anesthesia and rapid recovery are central in pediatric liver transplantation (PLTx). The aim of this study was to describe the intraoperative anesthetic management adopted by a dedicated team. Methods This is a retrospective study performed at IRCCS-ISMETT, a transplant center specialized in all solid organ transplantation. Main anesthetic strategies were restrictive crystalloid administration, multifactorial assessment for blood-products transfusion, and planned immediate extubation (IE). Pre-, intra-, and postoperative variables were extracted. Logistic regressions were applied to explore variables associated with PRBC transfusion and IE and subsequent multiple analyses on select variables. Results Ninety-nine consecutive recipients (0–17 years) between January 2018 and July 2023 were reviewed (75% living-related). Median fluid rates were respectively 9, 14, and 9 ml/kg/h during the pre-anhepatic, anhepatic and neohepatic phases. 34% of recipients required no PRBC, and 77% received < 20 ml/kg. Plasma or platelets were administered to 17 children. IE succeeded in 89 patients (90%). Median hospital stay was 18 days. One-year graft and patient survival were 99%. Transfusion-free PLTx was associated with lower tolerated intraoperative hemoglobin and higher mean arterial pressure, greater weight, and lower preoperative international normalized ratio (INR) or pediatric end-stage liver disease score. IE was associated with no requirement for vasopressors, shorter surgical time, and lower lactate levels at the end of operation. Conclusions Blood-sparing anesthetic strategies and IE are feasible in PLTx within an experienced multidisciplinary program, and are associated with favorable early postoperative outcomes.