Author Of 2 Presentations
POSTOPERATIVE RESPIRATORY FAILURE IN PEDIATRIC LIVER RECIPIENTS: DETERMINANTS AND ROLE OF NONINVASIVE CPAP.
- Fabrizio Chiusolo, Italy
- Linda Appierto,
- Marta Luisa Ciofi Degli Atti,
- Luigi Dei Giudici,
- Ilaria Erba,
- Ivano Farinelli,
- Alessandro Germani,
- Chiara Grimaldi,
- Francesco Polisca,
- Lucilla Rava',
- Emanuele Rossetti,
- Marco Spada,
- Francesca Tortora,
- Rosanna Pariante,
- Roberto Bianchi,
- Sergio Giuseppe Picardo,
Abstract
Background
Postoperative respiratory failure (RF) after pediatric liver transplantation (LT) is associated to high rate of morbidity and mortality due to this procedure. Use of noninvasive ventilation (NIV) for management of RF in postoperative period is debated.
Objectives
Evaluate perioperative risk factors of RF treated with CPAP in pediatric patients undergone LT.
Methods
Single center retrospective experience. Population was divided in two group based on the need of NIV after extubation. Preoperative, intraoperative and postoperative variables were collected to understand determinants of RF treated by CPAP by multivariate logistic model.
Results
In this retrospective cohort, 172 pediatric patients undergone to LT. Ninety four patients (94/172) developed RF after extubation and were treated with helmet CPAP. No differences were found between the two groups for type of graft, donor, surgical complications, infection rate. Patients treated with CPAP received more blood transfusion, and abdominal mesh wall was inserted. At multivariate analysis, biliary atresia (OR=3.6, 95% CI 1.3-9.8, p=.01), PELD>22 (OR=1.03; 95% CI 1.0-1.07, p=.02) and use of vasopressors during intraoperative period (OR=2.9; 95% CI 1.4-6.0, p=.005) expose pediatric liver recipient to development of postoperative RF treated with CPAP. Weight > 10 kg (OR=0.9, 95% CI 0.93-0.99, p=.03) could reduce the risk of postoperative RF. In the NIV group rate of intubation for NIV failure was 7.4% (7/94).
Conclusion
Biliary atresia, PELD>22 and use of intraoperative inotropes/vasopressors expose pediatric liver recipients to a greater odds of developing postoperative RF. CPAP application in early post-transplant period may be a good choice to treat postoperative RF after major abdominal surgery.
IS DEXMEDETOMIDINE EFFECTIVE AND SAFE FOR PROLONGED SEDATION IN CRITICALLY-ILL PEDIATRIC PATIENTS? A PROSPECTIVE MULTICENTER STUDY (PROSDEX)
Abstract
Background
Dexmedetomidine (DEX) is a selective-alpha-2-adrenergic-agonist recently authorized by Italian-Medicines-Agency for difficult sedation in pediatrics. Few data exist regarding prolonged infusions and no prospective study has systematically evaluated its efficacy so far.
Objectives
To evaluate DEX efficacy and safety for prolonged sedation in PICU.
Methods
Patients <18years receiving DEX≥24 hours in 9PICUs were included. Indications, dosages, efficacy and safety were systematically evaluated. Efficacy was defined as reduction of validated clinical-scores (Comfort-Behavior-Scale, CBS; Withdrawal-Assessment-Tool-1, WAT-1; Cornell-Assessment-of-Pediatric-Delirum, CAPD) and sparing of analgesics and sedatives. Every potential adverse-event (AE) was registered.
Results
A calculated sample-size of 163 patients (median-age 13months, IQR 4-71) were enrolled. Main indication was adjuvant for drug-sparing (42.3%). Seven-percent of patients received a loading-dose. Median infusion-duration was 108 hours (IQR 60-168) with dosages between 0.4 (IQR 0.3-0.5) and 0.8mcg/kg/h (IQR 0.6-1.2). Median time of infusion-weaning was 24 hours (IQR 5-48). Twenty-three patients (14.1%) received DEX as solo-sedation, 61% with other sedatives, 81% with other analgesics. After DEX-starting, CBS, WAT-1 and CAPD significantly reduced (p<0.001,p<0.001,p=0.027) as well as the dosages/kg/h of benzodiazepines, opioids, propofol and ketamine (p<0.001,p<0.001,p=0.001,p=0.027). Thirty-seven-percent of patients presented hemodynamic-AEs not-requiring intervention while 8.6% presented hemodynamic-AEs requiring intervention (79% dose-reduction). In multivariate models a loading-dose was associated with hemodynamic AEs (p=0.043) and the use of aminergic-inotropic-drugs was associated with severe hemodynamic-AEs (p=0.011).
Conclusion
DEX prolonged infusion assures comfort, allows sparing of opioids and benzodiazepines and helps to treat withdrawal-syndrome and delirium. AEs are mainly hemodynamic and easily reversible with dose-reduction. The loading-dose and the concomitant use of aminergic-inotropic-drugs are independent risk factors for hemodynamic-AEs.