Failure of Immediate Tracheal Extubation After Liver Transplantation - A Single Center Experience

Abstract

Fast tracking approaches in liver transplantation include postoperative extubation immediately after surgery in the operating theatre. Based on the experience of 837 liver transplantations performed between 01/97 and 05/05, we report on the safety and feasibility of this procedure in almost 80% of transplant recipients, without increasing the incidence of subsequent reintubation (11%). This patient population experienced significantly higher survival compared to patients in whom extubation succeeded at the intensive care unit (p<0.02). Special attention was required for recipients with acute liver failure or retransplantation. These patients did not participate in fast tracking protocols, as demonstrated by a multivariate regression analysis. In this context, failure of immediate tracheal extubation was independent of cold ischemic time, duration of surgery, donor / recipient age or gender, extent of preservation injury, or type of organ donation (postmortal vs living-related). ROC analysis revealed that only intraoperative transfusions of 6 units of red blood cells were associated with primary extubation in the operating theatre with high sensitivity and specifity. To conclude, postoperative mechanical ventilation is justified only in a small cohort of recipients. For the vast majority of patients, immediate postoperative tracheal extubation should be the standard procedure after liver transplantation.

Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes

“…Conversely, those in the delayed extubation group had a mean postoperative intubation duration of 3.2 days and a reintubation rate of 11.5%. Other reports have confirmed that patients who remained intubated post‐transplant had considerably higher rates of reintubation 18,19 …”

“…Other reports have confirmed that patients who remained intubated posttransplant had considerably higher rates of reintubation. 18,19 Few studies have evaluated the effect immediate extubation may convey on postoperative recovery. By performing immediate extubation, patients likely experience improved early mobility, reduced overall sedation and analgesia requirements, decreased postoperative positive pressure ventilation, and improved hemodynamics, all of which can impact early postoperative recovery.…”

Predictors of success of immediate tracheal extubation in living donor liver transplantation recipients

“…14 In contradiction to our study, Hoffmeister and colleagues declared no statistically significant difference between the two groups as regards the duration of surgery. 1 Also, Biancofiore et al found that the duration of surgery had no significant influence on the time of extubation. 6 …”

“… 12 Hoffmeister and colleagues found a highly significant difference in the amount of intraoperative transfused blood products between the extubated and non-extubated groups. 1 Zeyneloglu et al, when comparing extubated with non-extubated patients, found that those extubated had lower transfusion requirements. 13 Blood transfusion requirements were lower in our study, which may be attributed to the routine use of cell salvage, lower triggers for transfusion and different surgical techniques.…”

“…Orthotopic liver transplantation (LT) is the definitive treatment for acute liver failure, end-stage liver disease (ESLD), advanced liver cirrhosis, and liver tumors. 1 In our center we previously encouraged that leaving the patient sedated on mechanical ventilation is the standard care following LT. Clinicians believe that this type of clinical management improves outcomes by providing a smooth transition to the recovery phase and reducing physiological stress caused by awakening and spontaneous ventilation. This had remained the common practice despite the lack of evidence that routine postoperative ventilation or intensive care unit (ICU) admission prevents perioperative complications or benefits donor organ function.…”