Abstract
Background
Heart-lung transplantation is a critical intervention for pediatric end-stage cardiopulmonary diseases, including severe pulmonary hypertension. Post-transplant rejection, predominantly pulmonary, poses significant challenges. Tubeless spontaneous ventilation is an emerging anesthetic modality that improves prognosis by minimizing the risk of mechanical ventilation.
Case Description
This case report details a 15-year-old male patient who met the indications for combined heart-lung transplantation due to severe pulmonary hypertension in combination with right heart failure. The patient underwent combined heart-lung transplantation under tubeless spontaneous ventilation anesthesia. On postoperative day 6, the patient was observed to have early signs of pulmonary rejection, which was confirmed by testing for non-human leukocyte antigen antibodies. A tailored immunosuppressive regimen, including mycophenolate mofetil, methylprednisolone, and tacrolimus, was initiated. The patient also received antimicrobial treatment, along with nutritional support. On postoperative day 15, chylothorax was diagnosed, which was managed through fasting and modification of antifungal therapy due to hepatic dysfunction. Furthermore, exercise rehabilitation constitutes a significant component of the treatment regimen that patients receive. A phased rehabilitation program is a structured, multifaceted approach to recovery that encompasses all aspects of the patient’s hospitalization. It incorporates active and passive physical activities, postural and endurance training, respiratory muscle training, and other exercises, all meticulously designed to address the patient’s specific needs and facilitate their recovery. The patient exhibited a marked recovery in clinical symptoms by day 23 and was subsequently discharged from the hospital.
Conclusions
Tubeless anesthesia has been demonstrated to expedite postoperative recovery and mitigate pulmonary complications. Early rejection detection, tailored immunosuppression, and multidisciplinary coordination were instrumental in overcoming challenges. This case underscores the potential to reduce morbidity and highlights integrative strategies for optimizing transplant outcomes in children, emphasizing personalized care and vigilant monitoring.
Keywords: Heart and lung transplantation (HLT), tubeless, spontaneous ventilation, graft rejection, case report
Highlight box.
Key findings
• The comprehensive management encompassing tubeless anesthesia, perioperative weight optimization, structured pulmonary rehabilitation, and targeted symptom control plays a pivotal role in mitigating post-transplant rejection episodes among adolescent heart-lung transplant recipients.
What is known and what is new?
• Heart-lung transplantation is considered the definitive therapeutic option for children with bilateral end-stage cardiac and pulmonary failure. However, this procedure remains extremely rare in clinical practice. Post-transplant pulmonary rejection is a major challenge in pediatric heart-lung transplantation.
• This case highlights the first application of tubeless anesthesia in pediatric heart-lung transplantation, emphasizing its role in mitigating pulmonary complications.
What is the implication, and what should change now?
• In this case, nursing interventions were enhanced through innovations in anesthesia for heart-lung transplantation surgery. In addition, multidisciplinary collaboration is an essential process for optimizing the prognosis of complex pediatric cases.
Introduction
Since the first successful heart and lung transplantation (HLT) in 1981, it has been established as an effective treatment for end-stage cardiopulmonary disease (1), especially for pediatric patients with severe pulmonary hypertension and Eisenmenger syndrome (2). Due to its complexity, pediatric HLT is rarely performed. According to the International Society for Heart and Lung Transplantation, from 2008 to 2018, there were a mere nine pediatric HLT cases reported annually, with a mere three in 2018 (3). Over the past 30 years, the 5-year survival rate for pediatric HLT has improved to 49% (4,5). Post-transplant graft rejection remains a significant challenge, with pulmonary rejection occurring more frequently than cardiac rejection and impacting long-term outcomes (6).
Tubeless is an innovative anesthetic technique that preserves spontaneous breathing during surgery, enabling patients to avoid the risks associated with general anesthesia, minimize sedative and analgesic use, and reduce mechanical ventilation-related lung injuries and pulmonary complications by utilizing non-tracheal intubation (7,8). This technique in lung transplantation reduces secondary damage to the donor lung after transplantation, which is essential for improving patient prognosis (9). This study provides healthcare professionals with valuable insights by summarizing, for the first time, the experience of caring for an adolescent after tubeless HLT. We present this article in accordance with the CARE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-253/rc).
Case presentation
A 15-year-old male with a 13-year history of dyspnea on exertion was admitted to our hospital on March 21, 2024, for preoperative evaluation of heart-lung transplantation. The patient’s right heart catheterization demonstrates severe precapillary pulmonary arterial hypertension, with markedly elevated mean pulmonary artery pressure 78 mmHg, pulmonary vascular resistance 17.1 Wood units, and total pulmonary resistance 21.2 Wood units, alongside low cardiac index 1.9 L/min/m2 and elevated right atrial pressure 19 mmHg, fulfilling criteria for high-risk pulmonary arterial hypertension per the European society of cardiology and the European respiratory society guidelines (10). Chest computed tomography confirms pulmonary hypertension with right heart enlargement. Given the WHO Functional Class III symptoms, mean pulmonary artery pressure >50 mmHg, cardiac index <2.0 L/min/m2, and pulmonary vascular resistance >15 Wood units, this represents end-stage pulmonary arterial hypertension with poor prognosis.
After a multidisciplinary team discussion, specialists in cardiothoracic surgery concluded that the patient was a suitable candidate for lung transplantation. However, given his right ventricular dysfunction, ruptured tricuspid chordae tendineae with severe regurgitation, right ventricular enlargement, and left ventricular compression, it was anticipated that postoperative weaning from cardiopulmonary bypass would be challenging and unpredictable if he underwent double-lung transplantation with tricuspid valve repair alone. Therefore, heart-lung transplantation was considered the optimal surgical approach.
A comprehensive pre-operative evaluation and tubeless HLT were carried out on 31 October 2024. This case employed a non-paralytic anesthetic approach, maintaining spontaneous respiration via laryngeal mask airway with endotracheal intubation at 12–20 breaths/min. The anesthesia regimen combined epidural anesthesia with vagal nerve block, supplemented by intravenous infusion of propofol, remifentanil (0.1 µg/kg/min), and dexmedetomidine (0.5 µg/kg/h) for deep sedation and analgesia. The surgery was uneventful.
Postoperatively, the patient was transferred to the cardiothoracic intensive care unit with bilateral chest tube drainage, supported by non-invasive ventilation and venoarterial extracorporeal membrane oxygenation, which was weaned on postoperative day (POD) 3. On day 6, the patient tested positive for non-human leukocyte antigen (non-HLA) antibodies, with crackles in the lower lung lobes, diffuse infiltrates on imaging, and intermittent arrhythmias, suggesting lung rejection. Anti-rejection therapy with mycophenolate mofetil, methylprednisolone, and tacrolimus was initiated, with dosages adjusted based on serum levels. On day 12, the patient was transferred to the transplant ward, with thymoglobulin added for enhanced immunosuppression. The patient received combined antimicrobial therapy with linezolid, teicoplanin, cefoperazone-sulbactam, supplemented by voriconazole for antifungal prophylaxis and ganciclovir for antiviral treatment, and nutritional support. On POD 15, chylothorax was confirmed by positive pleural fluid analysis, prompting initiation of fasting. Hepatic dysfunction was evidenced by elevated liver enzymes (total bilirubin 23.1 µmol/L, alanine aminotransferase 121.0 U/L, aspartate aminotransferase 50.8 U/L), necessitating substitution of voriconazole with posaconazole for antifungal treatment. By day 23, the patient was free of cough, sputum, and fever, with improved lung expansion and reduced pleural effusion on chest radiograph. The patient’s condition stabilized, and he was subsequently discharged.
All procedures performed in this study were by the ethical standards of the institutional and/or national research committee(s) and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s parents to publish this case report and accompanying images. A copy of the written consent form is available for editorial review.
Nursing care
Personalized preoperative management strategy for the prevention of early allograft rejection
Weight reduction
The patient’s height was 167 cm, weight 84 kg, body mass index (BMI) 30.8 kg/m2, body fat percentage 43.1%, skeletal muscle mass 45.7 kg, and basal metabolic rate 1,685 kcal. Before surgery, the patient’s nutritional status was assessed using Nutritional Risk Screening 2002, scoring 1 point. Based on this, a dietitian and case manager developed a weight reduction diet plan. The patient required 1,400–1,600 kcal daily, with 70–75 g of protein daily. The case manager provided the patient’s parents with a dietary checklist and health counselling, recommending low-carb, low-fat, high-protein foods (e.g., eggs, fish, and chicken breast) while advising against fatty and organ meats. This dietary approach aimed to maintain stable weight loss, reduce the risk of rejection, and improve the patient’s quality of life (11,12).
Adjustments were made as needed. The patient followed the diet for one month, reducing weight to 76.7 kg one week before surgery. A multidisciplinary team confirmed the patient had reached the target weight for transplantation.
Monitoring and management of early rejection
Monitoring of symptoms associated with rejection reactions: the patient developed crackles in the lower lung fields on POD 6, accompanied by radiographic evidence of pulmonary infiltrates and pleural effusion. Intermittent arrhythmias were documented during cardiac monitoring. Non-HLA antibody testing returned positive results during this period. Surveillance for rejection included daily clinical assessments, serial imaging studies, and protocol-based laboratory testing.
Immunosuppressive therapeutic regimens: the patient received a triple maintenance regimen of tacrolimus, mycophenolate mofetil, and low-dose methylprednisolone. Tacrolimus trough levels were targeted at 15–18 ng/mL, with dose adjustments based on therapeutic drug monitoring. The transplant nurse coordinated medication administration under physician supervision, while the case manager provided standardized health education and a written medication adherence plan to the patient and parents.
Management of drug monitoring and adverse reactions: the transplant nurse closely monitored the patient’s 12-hour trough levels of tacrolimus. The nursing team established a medication schedule, with blood draws at 6:30 and 18:30 daily, drug administration at 7:00 and 19:00, and meals at 8:00 and 20:00. The patient was instructed to fast for 3 hours before tacrolimus intake and to wait 1 hour after dosing before eating. Additionally, the nurse closely monitored B-type natriuretic peptide levels and assessed for symptoms such as dyspnea and chest pain. If B-type natriuretic peptide levels significantly increased, the nurse promptly notified the physician and coordinated with bronchoscopy or chest computed tomography scans.
Given the patient’s postoperative medication regimen and BMI of 27.2 kg/m2 after weight loss, postoperative hyperglycemia was anticipated. Consequently, the nurse monitored early postoperative blood glucose levels, measuring pre-prandial glucose three times daily and recording it in the electronic medical record. The physician was notified when fasting glucose exceeded 7.0 mmol/L persistently. A summary of the treatment and events is presented in Figure 1.
Figure 1.
Timeline of treatment events. Anti-infective therapy was discontinued on November 20, and anti-rejection therapy was terminated on November 22. ATG, anti-thymocyte globulin; Hb, hemoglobin; WBC, white blood cell count.
Phased cardiopulmonary rehabilitation
The healthcare team will encourage patients to engage in early rehabilitation exercises when clinical conditions permit (13). In this case, the rehabilitation therapist and cardiopulmonary rehabilitation nurse developed a phased rehabilitation exercise program, including active or passive movements, bedside exercises, limb resistance training, and respiratory muscle strength training (14).
Stage 1: Early postoperative rehabilitation care with noninvasive ventilator-assisted transitional ventilation
Early limb mobilization: on POD 3, following extracorporeal membrane oxygenation discontinuation, the patient initiated active limb exercises in bed under the guidance of a cardiopulmonary rehabilitation nurse. The patient performed upper-limb resistance training with small dumbbells, including arm muscle stretching, elbow flexion-extension, and chest-expanding exercises (2 sets of 10 repetitions each). Lower-limb exercises included straight-leg raises, leg adduction and flexion, and ankle pumps (2 sets of 20 repetitions each). Exercise intensity was progressively increased based on the patient’s subjective fatigue, heart rate, and oxygen saturation before and after exercise (11). By POD 11, the patient’s tolerance improved, and bedside sitting activities were initiated. The bed was incrementally elevated to 30°, 60°, and 90°, with a final goal of sitting upright for 30 minutes twice daily (14). The patient also performed upper-limb exercises such as arm extension, external and internal rotation, chest-expanding movements, and lower-limb exercises like leg lifts, kicking, and cycling in bed (2 sets of 30 repetitions each).
Respiratory function training: under the guidance of a cardiopulmonary rehabilitation specialist nurse, the patient had mastered the techniques of “pursed-lip and diaphragmatic breathing” preoperatively, performing daily exercises consisting of 2 sets with 50 repetitions per set.
Stage 2: Transfer to the organ transplantation unit for continuous treatment
Rehabilitation assessment: on POD 13, the patient initiated pulmonary rehabilitation exercises. A cardiopulmonary rehabilitation nurse assessed the patient’s lung function and muscle strength using a smart respiratory trainer (including peak inspiratory and expiratory pressures, forced vital capacity, etc.), resting SpO2 and heart rate. The patient’s manual muscle testing of the limbs was graded as 5, with the ability to stand with assistance. The patient wore a portable pulse oximeter during exercise, and the nurse closely monitored post-exercise SpO2 and heart rate.
Exercise rehabilitation training: the cardiopulmonary rehabilitation nurse developed a daily rehabilitation exercise plan, including resistance training for the limbs, walking, standing and stepping exercises at the bedside, and cycling (11). The patient followed this plan, resting for 10 minutes after each exercise session, with a total daily exercise duration exceeding 1 hour. The detailed exercise plan is shown in Table 1.
Respiratory rehabilitation training: the cardiopulmonary rehabilitation nurse prescribed a respiratory exercise regimen using the XEEK (Xiamen, China) portable smart respiratory trainer based on the patient’s condition. The patient combined pursed-lip diaphragmatic breathing with the trainer to strengthen inspiratory and expiratory muscles, with the nurse progressively increasing the training intensity according to the patient’s tolerance (14). The patient performed inspiratory muscle training with a progressive resistive load, starting at 30% of the maximal inspiratory pressure. If the patient could not achieve 30% maximal inspiratory pressure, the maximum flow resistance load the patient could complete was selected. In the upright sitting position, the patient inhaled quickly and exhaled slowly through the trainer’s mouthpiece under the guidance of the rehabilitation nurse. Before each inhalation, the patient exhaled completely, rapidly and forcefully, then exhaled slowly without breathing. Respiratory muscle training consisted of 30 repetitions per set, twice daily (morning and afternoon), with each session lasting 15 minutes and intermittent rest as needed.
Table 1. Daily rehabilitation training plan for patients transferred to the ward during hospitalization.
| Daily training time | Rehabilitation exercise plan | Training frequency |
|---|---|---|
| 8:30, 13:00, 14:30, 17:00, 18:30, 20:30 | Walking training, with the assistance of the patient’s family, walking in the ward’s corridor for 5 minutes each time | 6 times per day |
| 8:50, 14:50 | Step by the bed for 5 minutes each time | 2 times per day |
| 9:10, 15:10 | Intelligent respiratory training device training lasts for 15 minutes each time | 2 times per day |
| 10:00, 16:00 | Upper limb movements (stretching, external rotation, internal rotation, circular drawing, etc.), each lasting 5 minutes; relax and stretch for 5 minutes; lower limb cycling, lasting 15 minutes each time | 2 times per day |
| 11:00, 19:30 | Following nebulization, conduct sputum expectoration training for 10 minutes per session | 2 times per day |
Management strategy for maintaining a negative fluid balance
The healthcare team collaboratively set nursing goals based on daily fluid intake, adopting an early postoperative 24-hour “negative fluid balance” strategy with no more than 500 mL difference between output and input. Nurses used infusion pumps to control the rate of fluid and drug administration, adjusting within a range of 50–100 mL/h; daily monitoring of non-invasive blood pressure (BP), central venous pressure, and urine output was performed to adjust fluid administration rates, volumes, and vasopressor use (15). Every 4 hours, nurses recorded fluid balance and weight changes in the electronic nursing system, including infused fluids, chest tube drainage, urine output, food water content (calculated using a food water content table), and insensible losses (sweat).
On POD 5, the patient’s urine output decreased significantly, with a diastolic BP of 40 mmHg despite continuous dopamine and epinephrine infusion. Considering systemic hypovolemia, the patient had a platelet count of 66×109/L and a hemoglobin (Hb) level of 60 g/L. The nurse administered two units of packed red blood cells, 1 unit of platelets, and 300 mL of fresh frozen plasma as per medical orders, followed by crystalloid infusion to restore systemic volume. On POD 6, post-transfusion assessment showed an Hb level of 71 g/L with slight improvement in anemia. The patient continued to receive red blood cells and plasma, with adjusted doses of dopamine and epinephrine, while nurses continuously monitored BP and urine output fluctuations. By POD 11, the patient’s BP was within the normal range, with an oxygen saturation of 99–100%, Hb level of 88 g/L, platelet count of 283×109/L, and albumin level of 41.3 g/L. Vasopressor support was gradually tapered.
Preventing and controlling infections
The patient had a weak cough and sputum clearance capabilities in this case. Serial blood tests showed significantly elevated white blood cells (WBC) and neutrophils. On POD 9, WBC count increased to 35.6×109/L with an absolute neutrophil count of 34.3×109/L. A deep sputum culture identified methicillin-resistant Staphylococcus aureus, and alveolar lavage fluid was detected in Candida albicans. Airway management is crucial for preventing and controlling pulmonary infections, with airway clearance techniques effectively removing secretions and improving lung infections (16). The nurse administered nebulized amphotericin B, levalbuterol, and ambroxol hydrochloride, with the patient in a semi-recumbent position for 15–20 minutes twice daily. After nebulization, the patient rinsed the mouth with warm water. The patient was then positioned on the side, and manual percussion was performed in an outward-to-inward and top-to-bottom sequence for 3 minutes per area (11). Under nurse guidance, the patient performed slow deep breaths (3–5 times), held the breath for 1–3 seconds, and produced three forceful abdominal coughs (11). External diaphragmatic pacing, which induces rhythmic diaphragmatic contractions, reduces the risk of pulmonary infections (17). The patient was placed in a supine position with pacing set at 9–12 cycles/min and a pulse frequency of 15–30 Hz, gradually increasing current intensity for 30 minutes twice daily.
On POD 15, imaging showed reduced left pleural effusion and decreased scattered infiltrates in the left lung. By POD 20, the patient had a normal temperature, no dyspnea, stable vital signs, and a WBC count of 4.6×109/L with an absolute neutrophil count of 8.4×109/L. A comparison of respiratory endoscopy images on POD 14 and at the first follow-up is shown in Figure 2.
Figure 2.
Bronchoscopy images showing improvement of the distal tracheal anastomosis. (A) Bronchoscopy on postoperative day 14 (November 14, 2024) showing inflammatory changes at the anastomotic site. (B) Follow-up bronchoscopy at first outpatient visit (December 10, 2024) demonstrating improved healing and reduced inflammation at the anastomotic site.
Post-discharge follow-up of the patient
At discharge, the case manager adjusted the patient’s diet plan, advising a low-fat diet with low-glycemic-index foods, restricted caloric intake, and increased vegetable consumption (12). The patient was scheduled for an outpatient follow-up one month post-discharge. During this visit, rejection monitoring and drug level testing would be conducted. The case manager would interpret the results, assess the patient’s home recovery progress, and provide instructions for the subsequent follow-up and relevant precautions.
Discussion
This case highlights the complex management challenges in pediatric HLT, where innovative techniques and multidisciplinary strategies addressed key issues, including tubeless anesthesia, obesity-related metabolic risks, rejection surveillance, immunosuppression balance, and infection prevention.
Advantages of tubeless anesthesia
The tubeless HLT approach provided triple benefits: avoiding ventilator-induced lung injury, preserving mucociliary clearance mechanisms, and reducing systemic inflammation (8,18). By maintaining spontaneous respiration, we observed accelerated postoperative awakening, a critical factor enabling our unusually early rehabilitation initiation (ambulation within 72 hours vs. conventional 5-day protocols) (9). This aligns with emerging evidence that minimizing mechanical ventilation may attenuate the ischemia-reperfusion injury cascade (18).
Obesity-related metabolic risks
The patient’s obesity, with a BMI of 30.8 kg/m2, posed significant perioperative challenges that required a comprehensive and tailored management strategy. Preoperatively, a structured intervention led to a 7.3 kg weight reduction. This weight loss was crucial in mitigating the known risks associated with obesity in the context of heart-lung transplantation. Specifically, it reduced the risk of primary graft dysfunction, for which obesity (BMI >30 kg/m2) is a known risk factor with an odds ratio of 2.1 (19), and also decreased the likelihood of acute graft-versus-host disease (20). The weight reduction improved the patient’s cardiopulmonary reserve, essential for better perioperative outcomes (21,22).
Intraoperatively, the patient’s obesity necessitated pharmacokinetic adjustments due to the upregulation of cytochrome P450 3A4, an enzyme involved in drug metabolism. This metabolic change required a 30% higher loading dose of tacrolimus to achieve the desired target trough levels (23). Ensuring adequate immunosuppression is critical to prevent rejection, and precise dosing adjustments were essential to maintain therapeutic levels of tacrolimus. Post-discharge, the patient was placed on a low-glycemic diet (12). This dietary intervention served a dual purpose. Firstly, it helped stabilize the metabolism of immunosuppressant drugs, which is particularly important given the altered pharmacokinetics associated with obesity. Secondly, it aimed to prevent new-onset diabetes, a condition that carries a 16% risk in patients treated with tacrolimus (24). By addressing both metabolic stability and diabetes prevention, the low-glycemic diet contributed to the overall management of the patient’s post-transplant care.
Rejection surveillance dilemmas
Our case exemplifies the diagnostic challenges in detecting pulmonary rejection, which often precedes cardiac rejection in combined transplants (25,26). The nonspecific presentation, with radiographic infiltrates mimicking infection, underscores the need for comprehensive evaluation when non-HLA antibodies are detected. While histological confirmation remains the gold standard (27), the risks of repeated invasive procedures led our team to initiate empiric anti-rejection therapy based on clinical constellation.
Immunosuppression balancing acts
The intensified immunosuppression regimen (tacrolimus/mycophenolate mofetil/steroids) mirrored lung transplantation protocols (26), reflecting the predominance of pulmonary complications in heart-lung recipients. Maintaining this balance was critical—while subtherapeutic levels risked rejection, excessive immunosuppression predisposed to infections and malignancies (28). Pediatric pharmacokinetic variability necessitated rigorous therapeutic drug monitoring (29), with our target range (15–18 ng/L) selected to accommodate the patient’s age and concomitant medication (30). This case highlights the importance of multidisciplinary management, where nurses ensured precise dosing while case managers addressed adherence barriers through structured education.
Infection prevention paradigms
This case exemplifies the high infection burden in pediatric HLT recipients, with reported rates reaching 90% (31), a consequence of both immunosuppression and rejection-impaired mucociliary clearance. The methicillin-resistant Staphylococcus aureus (MRSA)/Candida co-infection underscores the need for aggressive surveillance, particularly given infection’s role as the second leading mortality cause post-HLT (6). Our multimodal approach combined pharmacologic (nebulized antifungals/bronchodilators) and physical (percussion/diaphragmatic pacing) strategies, leveraging evidence that structured airway clearance reduces ventilator-associated infections (16) while external pacing maintains cough efficacy (17). The rapid WBC normalization (POD20) suggests this protocol may be particularly beneficial for patients with impaired spontaneous cough.
Early postoperative rehabilitation
In this case, the tubeless HLT approach enabled unusually early rehabilitation initiation, capitalizing on evidence that prompt mobilization reduces pulmonary complications (9). Our phased protocol, progressing from bed exercises to ambulation within 72 hours, aligns with data showing improved graft function when rehabilitation begins before POD 5 (14). Notably, the preserved lung function achieved through this regimen may buffer against rejection-related functional decline, though this requires further study in pediatric populations.
Fluid management strategies
Our strict negative fluid balance approach addressed the dual risks of volume overload in HLT recipients—hemodynamic compromise and immunologic activation. Excessive fluid administration disproportionately stresses the right ventricle, while pulmonary congestion may promote inflammatory cascades that prime rejection responses (32,33). The 500 mL output-input threshold was selected based on data showing this degree of negative balance optimally improves oxygenation without compromising end-organ perfusion (15). Notably, the POD 5 transfusion episode highlights the need for dynamic adaptation—while negative balance is generally protective, acute blood loss necessitates prompt volume restoration to maintain graft perfusion.
Conclusions
Tubeless HLT significantly reduces the risk of ventilator-associated injury and postoperative pulmonary complications. This technique enhances early recovery for HLT patients, as demonstrated by the case where the patient experienced faster awakening from anesthesia and fewer pulmonary complications. Additionally, the nursing team plays a vital role in optimizing care by adapting to the unique needs of tubeless HLT patients. This comprehensive, patient-centered approach, combining innovative anesthesia techniques with coordinated team efforts, is critical in managing the complexities of pediatric HLT cases.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were by the ethical standards of the institutional and/or national research committee(s) and the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s parents to publish this case report and accompanying images. A copy of the written consent form is available for editorial review.
Footnotes
Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-253/rc
Funding: This study was supported by the Health Commission of Guangdong Province, China and funded by the Science and Technology Program of Guangzhou Municipality of Traditional Chinese Medicine and Integrative Medicine (grant Nos. 20232A011011 and A2023415).
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-253/coif). The authors have no conflicts of interest to declare.
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