Preoperative Evaluation

• All pediatric patients listed for liver transplantation should be seen by anesthesia. After resident evaluation the case should be discussed with Dr. Passannante and one of the Pediatric Liver Call Team attendings.
• Preop evaluations should be placed in patient's chart and the yellow copy in the Liver Preop Notebook in the monitoring room between ORs 5 and 6.

Lines
CVP/Drip Lines: double lumen 5F Cook Kit

• 5 cm - infant and toddler
• 8 cm - small child
• 12 cm - large child
• 15 cm and 30 cm - femoral

• Radial or axillary line on either side
• Occasionally two arterial lines may be required

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IV solutions

< 1 year or <10 kg

• NS to dial-a-flow to gang of four to T-connector
• NS thru buretrol to dial-a-flow to double stopcock to short (non high  pressure) extension tubing (to one of two large bore central or peripheral lines).
• NS thru buretrol to dial-a-flow to double stopcock to long (non high pressure) extension tubing (to one of two large bore central or peripheral lines).
• D5 1/4 NS thru buretrol to dial-a-flew to extension set to T-connector (to a peripheral IV).
• Standard blood administration set up (blood administration set to Hot Line to extension set) - do not hang any fluids with this.
• Level one warmer in the room.

21 - 40 kg

• omit dial-a-flows
• omit buretrols, use minidrips

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Infusions
To be prepared 50 cc/syringe:

• Calcium Chloride
• 10 cc of 10% CaCl in 40cc NS (20mg/cc)
• 0.5 cc/kg/hr = 10 mg CaCl/kg/hr
• Dopamine:
• 6 x wt(kg) = mg of drug in total of 50 cc w/NS
• 1 cc/hr = 1 mcgg/kg/min
• Lasix
• 12 x wt(kg) = mg of drug in total of 50 cc w/NS
• 1 cc/hr = 4 mcg/kg/min = 0.24 mg/kg/hr
• KCl
• use standard 2 meq/cc concentration
• 0.5 meq/kg/hr = 0.25 cc/kg/hr
• note: this can only be given centrally and must be through a port proximal to the patient and with a continuous carrier

Non-anesthetic Drugs

• 100 to 250 cc of 5% albumin
• Epinephrine 10 mcg/cc (10cc syringe)
• 10% CaCl undiluted in 3 or 10 cc syringe
• Sodium Bicarbonate 1 mEq/ml
• Amikar
• Phenylephrine 40 mcg/ml (or more dilute)
• Mannitol 1 gm/4cc
• Will give 0.5 to 1.0 gm/kg just prior to anhepatic phase
• Insulin
• D50

Equipment

• Warming blanket
• ± heated circuit
• Warm room, plastic wrap
• Pediatric ABG, CBC and Coag tubes

Blood Products
In the Room

• Units of PRBC's >= patient's blood volume (est. 250 cc/unit)
• Units of FFP >= patient's blood volume (est. 250 cc/unit)

• The blood bank should have at least an equivalent (to what is in the room) amount of PRBC’s and FFP downstairs.
• In addition, platelets and cryoppt should be in the blood bank.
• Units of platelets available = 2 units/5kg (single pheresis unit = 6 random donor units)
• Cryoppt available = 20 cc/kg

Anesthetic Technique

• Induction: If IV is in place, then standard rapid sequence induction. If no IV, then will vary depending on the patient and anesthesia team.
• Maintenance: 02, vapor, narcotic technique, muscle relaxant of choice (renal route of excretion may be preferable).