Postoperative pain management of liver transplantation in cystic fibrosis: Is it time to start US-guided neuraxial blocks?

Cystic fibrosis (CF) is the most common life-limiting genetic disease in Caucasians. Declining lung function is the principal cause of death, but liver involvement can lead to the need for liver transplantation. General anesthesia has detrimental effects on pulmonary function, increasing perioperative morbidity and mortality in CF patients. Regional anesthetic techniques improve outcomes by reducing anesthetic drugs and administration of opioids, and hastening extubation, awakening, and restarting respiratory of physiotherapy. There is a growing evidence that thoracic epidural anesthesia is feasible in pediatric patients. Concerns about coagulopathy and immunosuppression have limited its use in liver transplantation. Ultrasonography is becoming an adjunct tool in neuraxial blocks, allowing faster and easier recognition of the epidural space, and reducing vertebral touch and number of attempts. In pediatric patients, it is still debated whether anesthesia has detrimental effects on cognitive development. Efforts to make regional techniques easier and safer by ultrasonography are ongoing. We report the first case of continuous thoracic epidural analgesia after pediatric liver transplantation in a 10-year-old boy affected with CF with macronodular cirrhosis. Despite a challenging coagulation profile, the echo-assisted procedure was safely performed and allowed extubation in the odds ratio, postoperative awakening and comfort, and quick resumption of respiratory physiotherapy.