title: Massive pulmonary hemorrhage before living donor liver transplantation in infants.
abstract: A massive pulmonary hemorrhage in patients with liver cirrhosis is a life-threatening complication that may result in a contraindication of a liver transplantation because of its high mortality rate. Herein, we present two infant biliary atresia cases that successfully underwent an LDLT that was followed by intensive respiratory care for the pretransplant massive pulmonary hemorrhage. Both cases exhibited severe respiratory failure (minimum PaO2/FiO2; 46 mmHg and 39 mmHg, respectively). To arrest the bleeding, we applied a very high positive pressure ventilation treatment (maximum PIP/PEEP; 38/14 cmH2O and 55/15 cmH2O, respectively), plasma exchange, several FFP transfusions, and recombinant factor VIIa via intrapulmonary administration. In addition, we used CHDF treatment, applied HFOV transiently, and treated the patient with inhalation of nitric oxide. Although we prepared ECMO for intra-operative use, both cases were successfully managed with conventional mechanical ventilation without using ECMO, which may have worsened the pulmonary hemorrhage due to the use of an anticoagulant. Use of an excessive positive pressure management, although it poses a risk for barotrauma, could be acceptable to arrest the pulmonary bleeding in selected cases of liver failure patients who have no time remaining before LDLT.
authors.affiliation: Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
authors.forename: Toshiharu
authors.initials: T
authors.lastname: Matsuura
authors.affiliation: Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
authors.forename: Koichiro
authors.initials: K
authors.lastname: Yoshimaru
authors.affiliation: Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
authors.forename: Yusuke
authors.initials: Y
authors.lastname: Yanagi
authors.affiliation: Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
authors.forename: Genshiro
authors.initials: G
authors.lastname: Esumi
authors.affiliation: Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Hayashida
authors.affiliation: Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
authors.forename: Tomoaki
authors.initials: T
authors.lastname: Taguchi
mesh_terms: D001656:Biliary Atresia / Q000150:complications* / Q000601:surgery*; D003422:Critical Care; D005260:Female; D006470:Hemorrhage / Q000150:complications / Q000175:diagnosis*; D006801:Humans; D007223:Infant; D008103:Liver Cirrhosis / Q000150:complications / Q000601:surgery; D016031:Liver Transplantation; D019520:Living Donors; D008168:Lung / Q000503:physiopathology*; D008171:Lung Diseases / Q000150:complications / Q000175:diagnosis*; D009569:Nitric Oxide / Q000627:therapeutic use; D010951:Plasma Exchange; D011175:Positive-Pressure Respiration; D013902:Radiography, Thoracic; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency; D016896:Treatment Outcome
chemical_list: D009569:Nitric Oxide
keywords: acute respiratory failure; biliary atresia; pediatric liver transplantation; pulmonary hemorrhage