Poster 22. Using a cardiac-output guided hemodynamic therapy algorithm reduces intra-operative fluid administration in LDKT with large donor-recipient size mismatch

Thursday 14 march 2019

12:48 - 12:51h

Categories: Klinisch, Postersessie

Parallel session: Postersessies 5 - Clinical

E.A.M. Cornelissen1, M. Voet2, A. Nusmeier3, J. Lemson3

1Amalia Children's Hospital, Radboud University Medical Center, Nijmegen2Dept. of Ped Anesthesiology,3Dept. of Ped Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands.

XIIPoster 5Background: A living donor kidney transplantation (LDKT) in young children requires a substantial increase in cardiac output (CO) to maintain good perfusion of the relatively large kidney. To achieve this, intra-operative hemodynamic therapy protocols commonly advise liberal fluid administration guided by high target central venous pressure (CVP) and arterial blood pressure (ABP). However, ABP and CVP are known to poorly estimate CO or organ blood flow. Such therapy may lead to good renal outcomes, but inherits the risk of severe fluid overload. Goal of our study was, first, to evaluate the feasibility of using a gold standard CO monitor for children, the transpulmonary thermodilution (TPTD) technique. Second goal was to evaluate whether a CO-guided hemodynamic therapy algorithm could induce a reduction in fluid administration, while achieving increased target CO and ABP.

Methods: Twelve consecutive LDKT recipients were studied. Heart rate (HR), ABP and CVP were measured continuously. A thermistor tipped catheter was inserted in the left arteria femoralis which was used to measure perioperative CO by TPTD measurements (PiCCO device, Pulsion). A CO-guided hemodynamic therapy algorithm steered hemodynamic management. Data on patient characteristics, fluid administration and vasoactive medication were collected. Hemodynamic values were obtained before (t0), during (t1) and after (t2) transplantation and were analyzed with repeated measurements ANOVA.

Results: Recipients were 3.2 (1.6-4.9) yrs of age and 14.1 (10.4-18) kg bodyweight. R/D weight ratio was 0.18 (0.11-0.28). No complications related to the TPTD-CO monitor were reported. Between t0 and t2, indexed CO increased with 31% (95% CI=15-48%). HR appeared to be the main contributor to the augmented CO and increased with 22% (95% CI=9-34%). Increase in indexed SV (stroke volume) was non-significant. MAP increased with 66% (95% CI=34-98%). Between t0 and t1, CVP did not change despite fluid administration. Mean fluid administration reduced from 166 ml/kg in the first two to 59 ml/kg (!) in the last ten patients. All kidneys showed diuresis shortly after reperfusion. Patient and graft survival were 100%.

Conclusions: In LDKT in young children TPTD-CO monitoring is a safe technique to guide hemodynamic therapy. Using a CO-guided hemodynamic therapy algorithm reduces intra-operative fluid administration while achieving increased CO and ABP and preserving good renal outcome. This might prevent fluid overload and subsequent tissue edema.