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Critical Care and Mechanical Ventilation Practices Surrounding Liver Transplantation in Children: A Multicenter
Danielle K Maue1, Mercedes Martinez2, Alicia Alcamo3
1Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.
Insights
Younger children and those with open fascia or higher MELD/PELD scores require more postoperative invasive mechanical ventilation (IMV) after liver transplant. Prolonged IMV is linked to complications, highlighting its importance as a clinical marker.
Area of Science:
- Pediatric critical care medicine
- Transplant surgery
- Pediatric gastroenterology and hepatology
Background:
- Liver transplantation in children is complex, often requiring intensive care support.
- Understanding factors influencing mechanical ventilation is crucial for optimizing outcomes.
Purpose of the Study:
- To identify characteristics and management strategies associated with the need for and duration of postoperative invasive mechanical ventilation (IMV) in pediatric liver transplant recipients.
- To describe critical care resource utilization in this patient population.
Main Methods:
- Retrospective, multicenter cohort study involving 330 children undergoing isolated liver transplantation between 2017 and 2018.
- Data collected from 12 U.S. pediatric liver transplant centers.
- Multivariable logistic regression analysis used to identify associated factors.
Main Results:
- Younger age, open fascia, larger center size, and higher MELD/PELD scores were associated with the need for postoperative IMV.
- Prolonged IMV (>24 hours) was associated with younger age, larger center size, and higher postoperative day 0 peak inspiratory pressure (PIP).
- Longer IMV duration correlated with increased bleeding, infections, graft loss, and reoperation.
Conclusions:
- Factors such as younger age, preoperative hospitalization, large center size, and open fascia predict IMV use.
- Younger age, large center size, and early postoperative respiratory mechanics (PIP) predict prolonged IMV.
- Prolonged IMV serves as a significant clinical marker for adverse outcomes post-pediatric liver transplant.
Objectives:
We aimed to determine which characteristics and management approaches were associated with postoperative invasive mechanical ventilation (IMV) and with a prolonged course of IMV in children post liver transplant as well as describing the utilization of critical care resources.
Design:
Retrospective, multicenter, cohort study of children who underwent an isolated liver transplantation between January 2017 and December 2018.
Setting:
Twelve U.S., pediatric, liver transplant centers.
Patients:
Three hundred thirty children post liver transplant admitted to the ICU.
Interventions:
None.
Measurements And Main Results:
Six patients died in our cohort. The median length of PICU stay was 4.5 days (interquartile range [IQR], 2.9-8.2 d). Most patients were initially monitored with arterial catheters (96%), central venous pressures (95%), and liver ultrasound (93%). Anticoagulation (80%), blood product administration (52.4%), and vasoactive agents (23.0%) were commonly used therapies in the first 7 days. In multivariable logistic regression analysis, age (adjusted odds ratio [aOR] 0.9 [0.86-0.95]), open fascia (aOR 7.0 [95% CI, 2.6-18.9]), large center size (aOR 4.3 [95% CI 2.2-8.3]), and higher Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores (aOR 1.04 [95% CI, 1.01-1.06]) were associated with postoperative IMV. In multivariable logistic regression analysis, postoperative day 0 peak inspiratory pressure (PIP) (aOR 1.2 [95% CI, 1.1-1.3]), large center size (aOR 2.9 [95% CI, 1.6-5.4]), and age (aOR 0.89 [95% CI, 0.85-0.95]) were associated with length of IMV greater than 24 hours. Length of IMV greater than 24 hours was associated with bleeding complications ( p = 0.03), infections ( p = 0.03), graft loss ( p = 0.02), and reoperation ( p = 0.03).
Conclusions:
Younger age, preoperative hospitalization, large center size, and open fascia are associated with use of IMV, and younger age, large center size, and postoperative day 0 PIP are associated with prolonged IMV on multivariable analysis. Longer IMV is associated with negative outcomes, making it an important clinical marker.
