Introduction: Orthotopic liver transplantation (OLT) is the only curative therapeutic option in children with end-stage liver disease (ESLD) or severe fulminant hepatic failure (FHF). However, these two groups of patients have certain differences in terms of development of collateral vessels and previous surgeries, which are more common in ESLD. Despite these differences the impact of these two conditions on the perioperative management of these two groups is not clear.

The purpose of this retrospective study was to assess the anesthetic management along with short-term morbidity and mortality in a series of pediatrics patients who underwent OLT for FHF or ESLD in a university hospital.

Materials and Methods: After obtaining approval from the Institutional Review Board, we retrospectively analyzed the records of children who underwent OLT from May 2002 to May 2012. The patients were categorized into two groups according to the reason for OLT: Group FHF (n=22) and group ESLD (n=19). Perioperative data related to anesthetic management and intraoperative events were collected along with information related to postoperative course and survival to hospital discharge. The patients fulfilled the King’s College Hospital Criteria for liver transplantation in FHF.

The information gathered from the subjects’ records included demographic features of gender, age, and weight; comorbidities; etiology of the liver failure; perioperative laboratory values; arterial blood gas analyses; use and volume of crystalloid, colloid, packed red blood cells, fresh frozen plasma, platelets, cell-saver, and 20% human albumin; anhepatic phase duration; vasopressors; anesthesia duration; and urine output. We also noted the lengths of stay (LOS) in ICU and hospital as well as the mortality rates.

Results: The mean age and weight for groups FHF and ESLD were 8.6 ± 2.7 years versus 10.8 ± 3.8 years (p=0.04) and 29.2 ± 11.9 kg versus 33.7 ± 16.9 kg (p=0.46), respectively. There were no differences between the two groups regarding the length of anhepatic phase (65±21min vs73±18 min,p=0.13) and operation time (9.1±1.6h versus 9.5±1.8h, p=0.23).The source of the donor liver was cadaveric in 4.5% of patients in group FHF and 21.1% in group ESLD (p=0.10). When compared with the patients in group FHF, those in group ESLD more commonly had a Glasgow coma score of 7 or less (32% vs 6%, p=0.04). The amounts of 20% human albumin, packed red blood cells, and fresh frozen plasma that were administered intraoperatively were not significantly different between the groups (p>0.05 for all). Patients in group FHF received more crystalloid solution intraoperatively than those in group ESLD (66±40 ml/kg versus 105±52 ml/kg, p=0.01). The groups were not significantly different in terms of intraoperative urine output and vasopressor requirements (p>0.05 for both). Compared with those patients in group FHF, those in group ESLD were more frequently extubated in the operating room (31.8% versus 89.5% p<0.001). Postoperative duration of mechanical ventilation (2.78±4.02 day vs 2.85±10.21 day, p=0.05), and the mortality rates at 1 year after OLT (7.3% vs 0%, p=0.09) were similar between the two groups.

Conclusions: Our results suggest that during pediatric OLT, those children with FHF require more intraoperative fluids and more frequent postoperative mechanical ventilation than those with ESLD. The higher rate of mechanical ventilation need after OLT for FHF has important clinical implications in terms of effective use of scarce intensive care resources.