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.