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578 Seven Day Anhepatic Survival in a 19 Month Old Child, an Interdisciplinary Challenge
  1. H Ringe1,
  2. V Varnholt1,
  3. W Luck2,
  4. G Puhl3
  1. 1Paediatric Intensive Care
  2. 2Paediatric Gastroentrology
  3. 3Department of General, Visceral, and Transplantation Surgery, Charite Campus Virchow, Berlin, Germany

Abstract

Objective Description of pediatric intensive care and surgical management in a 19 month old child after primary liver-graft-non-function, who was managed anhepatic for 8 days in total and re-transplanted twice.

Case Report A 19 month old boy, 10 kg bodyweight, with ALF of unknown origin received an adult left liver lobe. After all vessels were connected and re-opened the graft showed a massive swelling and perfusion failure due to fulminant micro-vascular rejection and was removed immediately. The portal vein was attached end-to-side to the cava inferior. Thereafter diffuse intra-abdominal bleeding occurred, requiring PPSB, factor VII, mass-transfusion and tranexamic-acid and the child was admitted to PICU sedated and ventilated.

To maintain ammonium, bile acids, bilirubin, and cerebral perfusion within thresholds continuous-single-pass-albumin-dialysis (SPAD) on turnover rates up to 150 ml/kg/h of hemodiafiltration/-filtration was used in total to bridge the anhepatic boy to his first (7 days) and second re-transplantation (1 day). Fresh-frozen-plasma to avoid hemorrhage, water-soluble vitamins, and amino-acids were continuously replaced.

Overall 16 surgical interventions (increased intra-abdominal pressure, portal vein kinking, portal and arterial thrombosis (second graft), removal of mesenterial lymphoid cysts, bile-duct-leak, second re-transplantation with cavo-portal anastomosis, and secondary abdominal wall closure with dermal-porcine-collagen, skin-mesh-grafts) and anticoagulation with argatroban were needed to save the boy.

During the 6 month total hospital stay, including 6 weeks on mechanical ventilation, multiple bacterial, viral and fungal infections were detected that required early and timely anti-microbiological treatment.

At 1.5 year follow up the child was alive with intact graft and showed no neurologic sequelae.

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