DOI: 10.1097/01.TP.0000160815.04784.4A

,  

,  

PMID: 15940059

Issn Print: 0041-1337

Publication Date: 2005/06/15


Print

Expanded Efficacy and Indication of Extracorporeal Membrane Oxygenation for Preoperative Pulmonary Bleeding on Pediatric Cadaveric Orthotopic Liver Transplantation

Shiro Fujita; Alan W. Hemming; Takahisa Fujikawa; Alan I. Reed; Richard J. Howard; Max R. Langham; David W. Kays; Michael A. Froelich; Fumiki Kushihata; Jota Watanabe

    loading  Checking for direct PDF access through Ovid

Excerpt

A 10-week-old girl was admitted for evaluation and management of acute fulminant hepatic failure. She had been healthy until she presented with acholic stool and jaundice at the age of 9 weeks. A work up showed ALT 787 U/L, total bilirubin 14.9 mg/dL, and severe coagulopathy with an INR of 3.4. Metabolic disorders and autoimmune liver disease were ruled out. Though viral etiology was strongly suspected, serologies were negative for Hepatitis A, B, and C viruses, Ebstein-Barr virus, cytomegalovirus, etc. She underwent plasma exchange to control coagulopathy. Her condition continued to worsen with the onset of encephalopathy, progressive ascites, and seizure activity. Due to the deteriorating condition, she was approved for liver transplant. The patient underwent liver transplantation using full-sized graft without complications on hospital admission day 10. Pathology on the native liver showed massive hepatic necrosis. No viral cytopathic changes were identified.
Initial postoperative course was uneventful until postoperative day (POD) 14 when AST and ALT began to elevate. Over the next several days, her mental status and transaminase worsened significantly. Biopsy showed severe acute hepatitis suspicious for viral origin. She developed acute renal failure due to foscarnet and cidofovir, and was placed on central venovenous hemodialysis (CVVHD) on POD 26. She developed pulmonary hemorrhage and respiratory failure on POD 27. Various ventilatory maneuvers including high frequency oscillatory ventilation and use of nitric oxide failed. A 15 Fr. cannula was inserted to her right internal jugular vein and venovenous extracorporeal membrane oxygenation (ECMO) was installed with a flow of 0.2–0.8 l/min. She was relisted for liver transplantation. On POD 28, she underwent second liver transplantation while on ECMO. Transplantation was performed uneventfully and ECMO was weaned and successfully discontinued. Total length of ECMO use was 4 days. Although she needed the third and fourth liver transplantation due to portal vein thrombosis and intrahepatic arteriovenous fistula respectively, she is currently doing fine 15 months after the last transplantation.
Indication of ECMO has been applied for patients with acute, potentially reversible, life-threatening respiratory failure which is unresponsive to conventional therapies. ECMO is currently used as a bridging device to lung and heart transplantation (1). One report showed that ECMO support after heart, lung, heart-lung, and liver transplants has yielded a 57% survival to discharge (2). ECMO has been used after liver transplant for critical pulmonary embolism which occurred during transplantation (3,4). To the best of our knowledge, however, this is the first case report that liver transplantation was performed successfully while the patient was on ECMO. Due to acute renal failure and pulmonary hemorrhage, the present patient was on CVVHD and ECMO during the second liver transplantation. Experience of device usage and satisfactory support system are essential in successful application of ECMO to such patients with critical conditions. Our case shows the extended efficacy and indication of ECMO as a bridge to pediatric orthotopic liver transplantation.
    loading  Loading Related Articles