Reduced use of intensive care after liver transplantation: Patient attributes that determine early transfer to surgical wards

Abstract

Part 1 of our report, presented in the same issue of the Journal, shows that immediate postoperative extubation and direct transfer to the surgical ward is safe and reduces reliance on the intensive care unit in most liver transplant recipients. However, there is no method to preoperatively predict which patients will need ventilatory support after surgery. To address this issue, we examined the relationship between perioperative patient attributes and extubation outcome in patients entered into our immediate postoperative extubation study from 1996 to 1998. Variables chosen stemmed from considerations in the literature. We examined the influence of 13 preoperative and 6 intraoperative factors on extubation outcome. Preoperative attributes included sex, race, diagnosis, United Network for Organ Sharing status, Child-Pugh score, presence of a portosystemic shunt, ascites, encephalopathy, coagulation, age, body mass index (BMI), creatinine level, and year of surgery. Intraoperative factors were type of surgery, surgeon, anesthesiologist, number of red blood cells administered, length of surgery, and surgical start time. Female sex (P ‫؍‬ .02), BMI of 32 or greater (P ‫؍‬ .015), portosystemic shunt (P ‫؍‬ .022), and encephalopathy (P ‫؍‬ .041) were associated with no attempt by the physician to extubate, whereas encephalopathy (P ‫؍‬ .01) and BMI of 34 or greater (P ‫؍‬ .002) were associated with failure to meet criteria for postoperative extubation (described in part 1 of this study). We conclude there are limited factors that predict an increased risk for postoperative respiratory failure in liver transplant recipients. Our results indicate that physicians are conservative in their approach to extubation immediately after surgery, and sole reliance on physician judgment to determine suitability for postoperative extubation leads to unnecessary use of postoperative cardiopulmonary support. (Liver Transpl 2002;8:682-687.)

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

“…This also applies for Child C patients and recipients with acute hepatic failure or retransplantation (mostly due to INF) [26], who in our analysis could only be extubated on the intensive care unit. Mandell et al reported by means of a multivariate logistical regression analysis of 147 patients, that encephalopathy and body mass index (>35) were criteria for failure of primary extubation in the operating theatre [27]. O'Meara et al reported on similar findings in pediatric transplantations [24], and Biancofiore et al reported of a multivariate logistical regression analysis of 168 patients who received primary extubation within the first three postoperative hours [14].…”

Perioperative Care of the Liver Transplant Patient

“…IPE may allow the patient to avoid ICU admission, reducing hospital length of stay and ICU-associated costs. 20,[23][24][25] However, safe avoidance of the ICU after LT requires careful redirection of nursing resources and very close collaboration among the anesthesiology, ICU, and ward teams. Indeed, others contend that a period of postoperative ventilation allows graft function to be consolidated with less sympathetic activation and protects the recipient from the risks of atelectasis, aspiration, or reintubation for surgical reexploration if required.…”

Anesthetic Management of Abdominal Surgery

“…After liver transplantation, patients can be extubated in the operating room (11)(12)(13)(14). On the other hand, close monitoring and laboratory tests have to be continued in the ICU.…”