Current issues in pediatric liver transplantation.

Pediatric patients with ESLD requiring liver transplantation often have a multitude of comorbidities ranging from pulmonary hypertension to renal and cardiovascular insufficiency that impairs our ability to safely care for these critically ill children. As organ allocation techniques advance, many of these patients may be healthier on arrival to the operating room. However, postoperative surgical complications and immunosuppressive regimens still daunt us. As we continue to care for these challenging patients, hopefully, advances in ESLD management and technology will dramatically improve outcomes in the future.

The influence of neurophysiologic monitoring on the management of pediatric cardiopulmonary bypass.

We describe a process by which we sought to determine how the addition of intraoperative neurophysiologic monitoring (IONM) impacted the management of cardiopulmonary bypass (CPB) during pediatric cardiac surgery. While maintaining a consistent team of surgeons, anesthesiologists, nurses, and perfusionists, a multi-modal, IONM program was established consisting of Near Infrared Spectroscopy, Transcranial Doppler, and eight channel electroencephalography. A retrospective review of cases from 1 year before the institution of the IONM program was compared with data obtained from cases performed after neurophysiologic monitoring was established as a standard of care for pediatric patients on CPB. This comparative analysis of CPB management revealed a significant increase in the use of donor blood added to the CPB circuit prime as well as in the maintenance of a higher hematocrit during the bypass period after the implementation of IONM. These changes in the management of pediatric CPB correlated with recommendations of previous studies that examined postoperative neurophysiologic outcomes, suggesting that these changes were not only consistent with best practices, but that the presence of IONM data facilitated a transition to evidence-based practice.