Critical Care and Mechanical Ventilation Practices Surrounding Liver Transplantation in Children: A Multicenter Collaborative*

Abstract

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.

Duration of Invasive Mechanical Ventilation Post-Liver Transplantation: Does One Size Fit All?*

“…Taking all the above together, this report by Maue et al (4) is a welcome addition to the literature. The large, multicenter dataset prompts us to think proactively about the anticipated clinical course of children in post-LT critical care.…”

“…In this issue of Pediatric Critical Care Medicine , Maue et al (4) discuss the clinical landscape of post-transplant critical care with a special focus on the duration and explanatory factors for IMV in children undergoing LT in 12 centers across United States. Of the 330 patients, 239 (72.4%) remained on IMV postoperatively, and 91 (27.6%) arrived to the PICU after having been extubated in the OR.…”

“…Unlike the adult population, children have varying etiologies in different age groups with different prognosis. Since the new study is retrospective, Maue et al (4) do not comment on the various causes of liver failure leading to LT, the intraoperative course, or the type and quality of liver graft, yet all these factors are extremely important in determining critical care utilization post-LT.…”

Editor’s Choice Articles for February

“…First, we have a feature article (7), with an editorial (8), about critical care and invasive mechanical ventilation (IMV) practices surrounding liver transplantation. The retrospective analysis comes from 12 PICUs in the U.S. and looks at the time course of IMV in 330 children.…”

Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes

“…Although immediate extubation is considered safe and effective in many adult liver transplant patients, pediatric anesthesiologists and intensivists remain more hesitant. A 2023 multicenter collaborative of pediatric intensivists showed that 72.4% of patients remained intubated post‐transplant 7 …”