Extubation in the operating room after pediatric liver transplant: A retrospective cohort study

Gurnaney, Harshad G.; Cook-Sather, Scott D.; Shaked, Abraham; Olthoff, Kim M.; Rand, Elizabeth B.; Lingappan, Arul M.; Rehman, Mohamed A.

doi:10.1111/pan.13313

Cited by 27 publications

(62 citation statements)

References 12 publications

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“…Most studies looking at predictors of successful extubation in children, defined as extubation without the need for prompt intervention or reintubation, have been retrospective cohort analyses of patients undergoing high-risk procedures such as cardiac surgery or liver transplantation. [5][6][7] Typically, these studies have centered around procedure-specific factors such as bypass time and amount of blood products transfused rather than more routine aBStract Background: Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children.…”

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confidence: 99%

Assessment of Common Criteria for Awake Extubation in Infants and Young Children

et al. 2019

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Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Practice patterns surrounding awake extubation of pediatric surgical patients remain largely undocumented. This study assessed the value of commonly used predictors of fitness for extubation to determine which were most salient in predicting successful extubation following emergence from general anesthesia with a volatile anesthetic in young children. Methods This prospective, observational study was performed in 600 children from 0 to 7 yr of age. The presence or absence of nine commonly used extubation criteria in children were recorded at the time of extubation including: facial grimace, eye opening, low end-tidal anesthetic concentration, spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful movement, movement other than coughing, laryngeal stimulation test, and oxygen saturation. Extubations were graded as Successful, Intervention Required, or Major Intervention Required using a standard set of criteria. The Intervention Required and Major Intervention Required outcomes were combined as a single outcome for analysis of predictors of success. Results Successful extubation occurred in 92.7% (556 of 600) of cases. Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds ratio, 4.44 (95% CI, 1.06 to 18.64; P= 0.042), and tidal volume greater than 5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately associated with the Successful group. A stepwise increase in any one, in any order, of these five predictors being present, from one out of five and up to five out of five yielded an increasing positive predictive value for successful extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95% CI, 90 to 100). Conclusions Conjugate gaze, facial grimace, eye opening, purposeful movement, and tidal volume greater than 5 ml/kg were each individually associated with extubation success in pediatric surgical patients after volatile anesthetic. Further, the use of a multifactorial approach using these predictors, may lead to a more rational and robust approach to successful awake extubation.

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Assessment of Common Criteria for Awake Extubation in Infants and Young Children

et al. 2019

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“…2 Early extubation intraoperatively may help reduce the length of stay in the PICU, thus fast-tracking recovery. 4 Gurnaney and colleagues 13 conducted a retrospective cohort study examining early extubation in the OR following liver transplantation in pediatric patients. A total of 64 patients were included in the study, and 37 of the patients underwent early extubation.…”

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confidence: 99%

Anesthetic Management for Pediatric Liver Transplantation in a Patient With Propionic Acidemia: A Case Report

Rodriguez

Tainsh

Varga

et al. 2021

Journal of Investigative Medicine High Impact Case Reports

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Propionic acidemia is an inborn error of metabolism characterized by accumulation of propionic acid due to deficiency of propionyl-CoA carboxylase. Main stay of treatment focuses on reducing dietary protein. However, orthotropic liver transplantation decreases the frequency of metabolic decompensations and improves life expectancy. We report a case of a 4-year-old boy undergoing orthotropic liver transplantation to treat propionic acidemia. This case highlights the use of intraoperative monitoring of metabolic markers like urine ketones, arterial ammonia, and lactate levels as these patients are at risk for hyperammonemia and metabolic acidosis. Also, the relevance in outcomes when performing early extubation in fast-tracking recovery.

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“…32 For instance, both duration of extubation and length of PICU stay are actionable determinants that could decrease overall length of stay, mitigate risk, and minimize wastage of valuable resources. 33,34 In order to optimize outcomes following LT, clinicians must adopt approaches to not only prevent complications, but also to successfully salvage patients after complications occur. 35 While some complications may not be preventable, the ability to rapidly diagnose and "rescue" a patient from a complication (minimizing the rates of FTR) relates to the quality of care of the health by the healthcare system.…”

Section: Enhancing Risk Stratification Of Patients On the Wait Listmentioning

confidence: 99%

“…In aviation safety research, many if not all fatal crashes were root‐caused to a preventable complication of poor communication, execution, or problem recognition, concepts that extend to peri‐operative graft loss or patient mortality . For instance, both duration of extubation and length of PICU stay are actionable determinants that could decrease overall length of stay, mitigate risk, and minimize wastage of valuable resources . In order to optimize outcomes following LT, clinicians must adopt approaches to not only prevent complications, but also to successfully salvage patients after complications occur .…”

Section: Introductionmentioning

confidence: 99%

Barriers to ideal outcomes after pediatric liver transplantation

Mazariegos

Kelly

et al. 2019

Pediatric Transplantation

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Long‐term survival for children who undergo LT is now the rule rather than the exception. However, a focus on the outcome of patient or graft survival rates alone provides an incomplete and limited view of life for patients who undergo LT as an infant, child, or teen. The paradigm has now appropriately shifted to opportunities focused on our overarching goals of “surviving and thriving” with long‐term allograft health, freedom of complications from long‐term immunosuppression, self‐reported well‐being, and global functional health. Experts within the liver transplant community highlight clinical gaps and potential barriers at each of the pretransplant, intra‐operative, early‐, medium‐, and long‐term post‐transplant stages toward these broader mandates. Strategies including clinical research, innovation, and quality improvement targeting both traditional as well as PRO are outlined and, if successfully leveraged and conducted, would improve outcomes for recipients of pediatric LT.

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Extubation in the operating room after pediatric liver transplant: A retrospective cohort study

Abstract: More than half of our pediatric liver transplant patients were successfully extubated in the operating room immediately following surgery. We believe early extubation to be safe when employed in selected subpopulations of pediatric patients undergoing liver transplantation.

Cited by 27 publications

References 12 publications

Assessment of Common Criteria for Awake Extubation in Infants and Young Children

Assessment of Common Criteria for Awake Extubation in Infants and Young Children

Anesthetic Management for Pediatric Liver Transplantation in a Patient With Propionic Acidemia: A Case Report

Barriers to ideal outcomes after pediatric liver transplantation

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