Reduced use of intensive care after liver transplantation: Influence of early extubation

Abstract

Postoperative ventilation and admission to the intensive care unit (ICU) is the standard of care in liver transplantation and comprises a significant proportion of transplantation costs. Because immediate postoperative extubation has been reported previously in a selected group of liver transplant recipients, we questioned whether this protocol could be extended to a larger group of patients. We also sought to determine the proportion of patients extubated immediately after surgery that could be transferred to the surgical ward without intervening ICU care. Of 147 patients studied in a prospective trial of sequential liver transplant recipients (who were not second-transplant recipients, United Network for Organ Sharing status 1, living donor transplant recipients, or dead before the end of surgery), 13 patients did not meet postsurgical criteria for early extubation and 111 patients were successfully extubated. Eighty-three extubated patients were transferred to the surgical ward after a routine admission to the postoperative care unit. Only 3 patients who were transferred to the surgical ward experienced complications that required a greater intensity of nursing care. A learning curve detected during the 3-year study period showed that attempts to extubate increased from 73% to 96% and triage to the surgical ward increased from 52% to 82% without compromising patient safety. The use of this protocol in our institution resulted in a 1-day reduction in ICU use in 75.5% of study subjects. We therefore conclude that the majority of liver transplant recipients can be extubated safely and admitted to the surgical ward after liver transplantation surgery, thus decreasing the cost associated with ICU care. (Liver Transpl 2002;8: 676-681.) S tandard postoperative care after liver transplantation includes mechanical ventilation and admission to the intensive care unit (ICU). 1,2 Clinicians believe this type of clinical management improves outcome by providing a smooth transition into the recovery phase and reducing physiological stress caused by awakening and spontaneous ventilation. 3,4 This has remained common practice despite a lack of evidence that routine postoperative ventilation or ICU admission prevents perioperative complications or benefits donor organ function. Rather, improvements in intraoperative medical management and technical surgical advances probably explain the recent trend toward fewer perioperative complications and improved patient survival. 5,6 It thus is reasonable to question whether physicians who use routine postoperative ventilation may be using unnecessary resources and incurring additional costs that do not enhance patient or donor organ outcome.Our preliminary study at the University of Colorado (Denver, CO) and University of California at San Francisco showed that immediate postoperative tracheal extubation was safe and cost-effective in a small group of patients who had perioperative characteristics associated with uncomplicated postoperative outcomes. 7 Results proved that the current ...

Critical Care Management after Adult Liver Transplantation

“…Uzamış mekanik ventilasyondan ayırmada hastaya uygulanan sedoanaljezik ilaçların günlük olarak kesilmesi ve spontan solunum denemelerinin yaptırılması önerilmektedir (2,6,8,12). Ekstübasyon öncesinde [solunum frekansı (dk)/tidal volüm (L)] oranının 100'ün altında olması (hızlı yüzeyel solunum indeksi) mekanik ventilasyondan ayrılmada başarıyı gösteren önemli prediktörlerden biridir.…”

“…gelişmeler sonucunda KT sonrası ortalama YBÜ'de kalış süresi oldukça kısalmıştır. Bununla ilgili olarak 1994 yılında yayımlanan bir derlemede ortalama postoperatif mekanik ventilasyon süresi 36 saat, ortalama YBÜ'de kalış süresi 6 gün olarak bildirilirken günümüzde birçok kurumda komplikasyonsuz olgularda ortalama YBÜ'de kalış süresinin 24 saatin altına indiği, hatta bazı kurumlarda seçilmiş hastaların YBÜ'ye hiç yatırılmadan PABÜ'de izlenip stabillendikten sonra servise çıkarıldığı bildirilmektedir (5,7,8).…”

Use of higher thromboelastogram transfusion values is not associated with greater blood loss in liver transplant surgery

“…Extubation and transfer to the surgical ward were based on a single set of criteria used by the ICU care team. 15 In the ICU, we checked the hemoglobin level, INR, and platelet count daily. Packed red blood cells (1 U) were transfused if the hemoglobin level was less than 8 g/ dL.…”

We have a liver. Have we got a bed? Intensive care support for liver transplantation surgery

“…A more radical approach is reported in two articles by Mandell et al Building on earlier experience, 3 they examined prospectively whether immediate postoperative extubation was possible in a large proportion of patients and whether this might allow the transfer of patients back to the surgical ward without intervening intensive care unit admission 4 : 83 of 147 patients followed this path, only 3 of whom later required more intensive nursing care. In interpreting these figures, we should remember that they were careful to exclude from their study a significant proportion of patients: retransplantation patients, UNOS status 1 patients, and living donor recipients.…”

“…The incidence of reintubation was as low as 1.8% of 111 immediately extubated patients. 4 Reintubation is a crude but clear measure of a complication necessitating a step up to intensive care. Larger studies are required to determine how safe it can be to plan to use a reduced level of nursing care for the management of a significant proportion of postoperative liver transplant patients.…”