21 years experience and recommendations in pediatric liver transplantation

Liver transplantation is the only treatment modality used in addition to palliative treatments in end-stage liver failure or some acute liver injuries. Mortality rates decrease as a result of advances in surgery, anesthesia and immunology, and the rate of transplantation increases. Success rates are increasing for each age group with close follow-up and new procedure. This makes anesthesiologists more confronted with pediatric patients. In our study, preoperative, intraoperative and postoperative data of 95 patients who underwent liver transplantation in the 0-18 age group between the years 1997-2018 in Akdeniz University Faculty of Medicine Hospital were reviewed retrospectively and recommendations were made for the future. Intraoperative data was missing in 47 of 95 cases However, these patients were not excluded from the study in order to use their existing data. Intraoperative data were evaluated from 48 patients. Liver transplantations performed in a 21-year period were evaluated before 2010 and from 2010. Statistical comparison of the data was done in groups and in general. In our study, the mean age of the patients was 89.03±64.45 months. The age, the mean weight and height were lower from 2010 than before 2010. When the etiology of hepatic insufficiency was evaluated, in contrast to many studies the most common cause was PFIC (12,6%), not biliary atresia, In our study, besides the Child-Turcotte-Pugh Score which is known to be a good objective marker in determining prognosis and shows the degree of liver failure, the MELD score which is known to better reflect prioritization and 3-month mortality was also included. PELD in patients under 12 years and MELD score in patients over 12 years were evaluated. The highest rate of transplantation was observed in Child C (40%) patients. There were no significant differences in terms of PELD, MELD and Child classification before 2010 and from 2010. In our study, donor type was 54.7% cadaver and 45.3% living donor. While the number of cadaver transplantations before 2010 was higher (84.6%), the rate of transplantation from living donors from 2010 was found to be 56.5%. In addition to liver failure, chronic kidney disease was the most common concomitant disease in patients scheduled for transplantation (12.6%). When the intraoperative data of the patients were examined, tiyopental was the most commonly used anesthetic in induction before and after 2010. The preference for narcotic analgesic used in induction is fentanyl 97.9%. Before 2010, the first choice of neuromuscular blocker agents was vecuruonium, whereas rocuronium was never used. Since 2010, the contribution of early extubation to early recovery and adjustment of postoperative outcomes has been emphasized in various planes, so vecuronium and cisatracurium use has decreased and rocuronium has become the first choice. As maintenance, the majority of the patients were given narcotic analgesic and neuromuscular blocker infusion with volatile anesthetic. Desflurane was found to be the most preferred volatile agent by years and overall. In our study, intraoperative albumin use increased significantly from 2010, calcium use has been reduced due to better blood gas analysis and replacement by blood gas status. Although the total fluid and colloid or crystalloid use were not found to be statistically significant, the amount of fluid used decreased in from 2010. Gelatin was first in the colloid preference and 1/3 isodex was the first in the crystalloid preference. Furosemide was the first choice for intraoperative diuretic use. The use of mannitol was absent before 2010 but after 2010 it was used 7.1% and in combination with furosemide 14.6%. The recent studies show that in liver transplantation, replacement of blood and blood products significantly increases complication rates and mortality. In our study, it was observed that the use of blood and blood products decreased significantly from 2010. In addition, there was a significant decrease in dopamine use and an increase in steradine use from 201. The main reason for this situation is that studies supporting the use of dopamine renal dose is not beneficial. In our study, no significant difference was found between the years in terms of operation time, complication, acute rejection, retransplantation rates, extubation and ICU stay. From 2010, reintubation rates decreased significantly. Regarding the postoperative mortality rate, 64% of the patients died in the first 30 days, 16% in the first 6 months and 20% after the 6th month. According to years, although 30-day mortality increased from 2010, there is a significant decrease in mortality rates in the first 6 months and after the six months. The rates of postoperative surgical, respiratory, renal and infectious complications hemodynamic instability and need for vasopressor therapy, GIS bleeding, acute rejection, reoperation and retransplantation were significantly higher in patients with exitus compared to survivors. Successful extubation rates were high in the survivors. The mean RBC transfusion rate was 20 ml/kg. Postoperative complications and early graft loss were higher, but survival rates were lower in patients receiving RBC above 20 ml / kg. As stated in many studies, it was supported by our study that blood and blood product replacements increase morbidity and mortality. In addition, postoperative exubation time and ICU stay were significantly higher in patients receiving blood above 20 ml/kg. Our study supports that prolongation of the operation time reduces postoperative early extubation rates. As a result of early recovery, early extubation and shorter intensive care stays, the decrease in morbidity and mortality rates and the prevention of cost increases have been the subject of many new studies. In our study, it was found that patients who had early extubation had shorter intraoperative periods. However, there was no significant effect of prolongation on postoperative complication rates, successful extubation and reintubation rates, reoperation, retransplantation and early graft rejection. The patients were divided into 10 kg and less and over 10 kg. Extubation time and ICU stay were significantly shorter in patients over 10 kg. There was no significant difference in terms of postoperative complications and survival. In conclusion, the most important factor affecting mortality and morbidity in LIVER transplantations is the increase in clinical experience. Liver transplantations consist of stages in which hemodynamics may be unstable at any time and it is necessary to be prepared by anticipating these unstable stages. In this respect, it is very important that the anesthetist and surgical team work in harmony. It is obvious that all these difficulties need more attention as they will become more apparent in the pediatric age group. In the world and in our country, the sensitivity of the people to organ transplantation is increasing day by day and the number of donors and consequently transplantation rates are increasing. These increases indicate that anesthesiologists may encounter an increasing number of organ transplant patients of all age groups. Especially with the development of diagnostic methods in the neonatal and infant period, the number of patients who underwent liver transplantation is rapidly increasing. Therefore, more prospective studies are needed for more detailed data on liver transplantation in the pediatric age group.