Neonatal Transplant

Pediatric Critical Care Columnist · Feb 26, 2010

We do a significant number of neonatal/infant hearts (seems like most of our hearts are infants lately), but have had some serious problems with our infant livers.

One of the most alarming things with the workup to transplant is the volume of blood required for all the testing. You may feel like you're exsanguinating your patient. With neonatal hearts you may be doing ABO incompatible transplants; we've done quite a few and the outcomes are generally fairly good. They're complicated by the need for additional immunosuppressive drugs. We use ATGAM or sometimes RATGAM and adjust the dose based on the patient's lymphocyte count; typically they'll get it for 2 weeks post-transplant. Mycophenolate, if you're using it, is started immediately on admission and tacrolimus usually once the renal function has stabilized. Steroids start off with a large dose and then taper fairly quickly to a maintenance dose. Ganciclovir is used for CMV mismatch - recipient negative, donor positive or unknown. Mycophenolate and ganciclovir are cytotoxic so wear gloves when handling them and don't toss anything they've been in contact with into the regular trash.

Now livers present special difficulties and they are much too unstable for a single nurse to handle inthe first 24-72 hours. They have horrible coagulopathy and require large volumes of blood products. They bleed, they may develop compartment syndrome or thrombosis in any of the vessels, renal function is often quite marginal and pain is huge. As the blood is filtered through the liver and ammonia levels drop, you may notice a drastic increase in sedation requirements. And we've had a number of kids requiring CRRT post-op. Our outcomes in kids under a year are not the greatest and w'ere looking at ways to improve them; we seem to see a lot of thrombi leading to graft failure due to ischemia. One of the solutions we're trying is to leave the fascia open and just close the skin (or alternatively close everything with Goretex) for the first 48 hours or more, with a second look surgery either POD 1 or 2. It's too early to tell what effect that will have, but we had to try something.

One other thing about livers that I've learned from reading up on them (remember, my son has had a transplant) is that living-related donor transplants weem to do best in children under 2 years of age, The rationale escapes me at the moment, since it's 0420 on my second night shift...