Anesthetic Considerations

Children present anesthetic challenges different from those in adults, but those under 10 kg in size present unique anesthetic considerations. Intravenous access is best secured with a large single lumen tunneled catheter directly into the internal jugular or subclavian vein. Large bore catheters are essential for adequate fluid and blood replacement since babies have small circulating volumes which are rapidly depleted in the face of ongoing hemorrhage. In addition to a fluid replacement catheter, a double lumen central catheter is also desirable for drug administration. An arterial line is also essential. Tunneled catheters provide long term IV access in infants who may otherwise present great difficulties in drawing blood or starting IVs as outpatients.

Heat preservation may be a problem in small children who are often hypothermic during a long transplant. Devices to direct warm air along the body of an infant are very helpful in maintaining core temperature above 35° during the operation. Rapid infusion systems should be available if blood loss is anticipated to be heavy. Cell saver devices are impractical in children less than 10 kg in size because of the relatively small volume of blood lost in these children.

It is useful to have at least two anesthetists who are experienced in the care of children during a transplant operation. One set of hands, however knowledgeable, may not be sufficient to deal with the many tasks that are necessary for a successful anesthetic. Blood monitoring for blood gases, serum electrolytes, calcium, magnesium and blood counts should be done at least once per hour, even in stable situations. Monitoring of coagulation parameters is essential for the management of the bleeding complications often seen during a liver transplant. A thromboelastogram device may be helpful in pinpointing a coagulation defect in the face of ongoing bleeding with abnormal bleeding times.

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