Zeynep Ersoy

PiCCO Monitoring During Liver Transplantation for Pediatric Patients

Introduction Anesthetic management of pediatric liver transplant recipients (PLTR) is based on fluid management, adhering to hemodynamic goals and managing associated comorbidities. The PiCCO (pulse contour cardiac output) system gives validated intermittent cardiac output measurements by transpulmonary thermodilution and is less invasive than pulmonary artery catheterization. Monitoring the cardiopulmonary system of PLTR during surgery using PiCCO system is reflective of ongoing hemodynamic response to intraoperative maneuvers. We compare the intraoperative and postoperative parameters with hemodynamic volumetric parameters monitored by PiCCO system in PLTR during surgery. Materials and Methods In a retrospective analysis of PLTR from Sept 2014 to Oct 2017, demographic, laboratory and perioperative data were collected. Transpulmonary thermodilutions were performed at different times of surgery: beginning of surgery (To); before hepatectomy and after selective vascular exclusion (Tanhepatic); new hepatic phase (Tend). Hemodynamic volumetric parameters monitored by the PiCCO system were mean arterial pressure (MAP), cardiac index (CI), intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), systemic vascular resistance index (SVRI) and stroke volume variability (SVV). Results 41 PLTR (aged 4 mo to 17 y) underwent hemodynamic monitoring with PiCCO during LT. Measurements including CI, CVP and MAP were significantly lower during Tanhepatic phase when compared to To and Tend phases (p<.05 for all, Table). Patients whose mean Tend EVLWI measurements were >7 mL/kg; greater amounts of intraoperative blood transfused (p=.027), higher graft recipient body weight ratio (GRWR) (p=.016) and longer anesthesia times (p=.046) were seen. The mean Tend SVV measurements were >10 in patients who had a higher GRWR (p=.033). More blood transfusion was needed and higher GRWR was observed in patients with GEDV <650ml/m2 (p=.000). Patients with a mean Tend CI measurement <3L/min/m2 received more colloid transfusion and had longer anesthesia time during LT. Conclusion PiCCO monitoring enables flow and dynamic parameters which predict fluid responsiveness and help to make critical decisions to restore hemodynamic stability during pediatric LT. Table. No title available.

Renal Transplantation for VACTERL Syndrome

Introduction Abnormal localization of the right common and external iliac arteries is a rare vascular anomaly that may be associated with congenital renal or genitourinary malformations. Herein, we report a very rare case of a patient with VACTERL syndrome, having small bladder volume, end-stage renal disease (ESRD), and vascular abnormality, who also presented with an ascending aorta rupture, who was treated with ileobladder technique and renal transplantation (RT). Case Presentation A 15-year old male patient applied to our hospital with bladder volume problems in addition to VACTERL syndrome and was found to have abnormal right common and external iliac arteries during pre-operative imaging. Vascular supply to the right lower limb was derived from an anomalous branch from the left internal iliac artery which took on a convoluted course across the pelvis. The patient was on dialysis. First, we applied the ileobladder technique, after which time the patient presented with ascending aorta rupture that we treated with a graft. 6 weeks later, we performed a living-related right kidney transplant from the father, which was implanted on the left side of the iliac fossa by using an abnormal right iliac artery and normal left external iliac vein. The ureter was then implanted directly to the bladder. The patient is doing well. Conclusion RT can be successfully performed on patients with VACTERL syndrome in spite of small bladder volume and major vascular problems, such as rupture of aorta and abnormal localization of the iliac artery. Figure. No caption available.

Percutaneous dilational tracheotomy in liver transplant recipients

Liver transplant recipients (LTR) may require percutaneous dilational tracheotomy (PDT) during the immediate postoperative period or later because of need for prolonged mechanical ventilation or airway issues. However, despite the increased risk of bleeding and infections, there is little data regarding the safety and effectiveness of PDT in LTRs.