Immediate extubation after pediatric liver transplantation: A single‐center experience

Abstract

The care of pediatric liver transplant recipients has traditionally included postoperative mechanical ventilation. In 2005, we started extubating children undergoing liver transplantation in the operating room according to standard criteria for extubation used for general surgery cases. We reviewed our single-center experience to determine our rates of immediate extubation and practice since that time. The records of 84 children who underwent liver transplantation from 2005 to 2011 were retrospectively reviewed. The immediate extubation rate increased from 33% during 2005-2008 to 67% during 2009-2011. Immediate extubation did not result in an increased reintubation rate in comparison with delayed extubation in the intensive care unit (ICU). Patients undergoing immediate extubation had a trend toward a shorter mean ICU stay as well as a significantly decreased overall hospital length of stay. Our findings suggest that there is a learning curve for instituting immediate extubation in the operating room after liver transplantation and that the majority of pediatric liver recipients can safely undergo immediate extubation. Liver Transpl 21:57-62, 2015. V C 2014 AASLD.Received December 5, 2013; accepted September 14, 2014.In 1997, studies reported an increasing frequency of immediate extubation of adult liver transplant recipients in the operating room. 1,2 Subsequent studies showed no increase in reintubation rates, decreased postoperative days in the intensive care unit (ICU), and decreased associated costs with immediate extubation. 2 Despite this increase in the fast-tracking of adult liver transplant recipients, common management in pediatric liver transplantation has continued to include postoperative ventilation. 3 A recently presented abstract examining the Studies of Pediatric Liver Transplantation database demonstrated that among the 25 centers queried, those centers with an overall shorter hospital stay and lower costs had a shorter duration of postoperative intubation (2.7 days) in comparison with other centers (6.5 days). The authors concluded that early extubation may result in a decreased length of stay. 4 In 2005, we began immediately extubating pediatric liver transplant recipients if all team members were comfortable with that plan. The current study sought to (1) examine our rates of immediate extubation, (2) identify factors associated with immediate extubation or postoperative ventilation, and (3) evaluate postoperative outcomes after this practice change. PATIENTS AND METHODSApproval for the study and a waiver for consent were obtained from the institutional review board. We performed a retrospective review of the medical records of all pediatric liver transplant recipients from January 2005 through December 2011 at our institution. Patients with preoperative ventilator requirements were subsequently excluded from the analysis. Three patients were included in the data set twice for Abbreviations: BMI, body mass index; ICU, intensive care unit; MELD, Model for End-Stage Liver Disease; PELD, Pedia...

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

“…In this small, retrospective cohort study, we demonstrate excellent outcomes with management that include EE for the majority of patients. Specifically, we found that 58% of all patients who underwent a pediatric liver transplant at CHOP were successfully extubated in the operating room at the end of surgery, similar to a 64% rate reported for a select transplant patient group at another pediatric center . We observed a reduction in postoperative time spent in the PICU and the hospital overall in the EE group.…”

“…Other factors, such as health status and physical location (home vs hospital) before a liver transplant, duration of surgery, and need for vasopressor support, were minor factors in determining EE success after liver transplant . One pediatric report found that parenteral nutrition‐related liver disease and increased administration of pRBCs, FFP, and platelets are associated with the need to remain intubated postoperatively . Of note, short and similar anhepatic and surgical times comparing EE and DE groups suggest that surgical complexity is a less likely contributor to the outcomes measured than the primary hepatic condition and comorbidities.…”

“…A Safe Operating Room Extubation after Liver Transplantation (SORELT) scoring system developed for adults includes functional status before a transplant, the volume of pRBCs transfused, vasopressor requirement, end of surgery blood lactate concentration, and duration of surgery . For the pediatric recipients, the likelihood of postoperative mechanical ventilation is associated with increased blood products administered during transplant and a primary diagnosis of parenteral nutrition‐related liver disease …”

CPAP by helmet for treatment of acute respiratory failure after pediatric liver transplantation

“…26,30 Other studies reported extubation between POD 1 and 7. 9,31,32 Extubation in the operating room is safe and effective 13,14,27 in pediatric liver recipients with higher weight, 13,27 lower PELD, 14,27 and who received lower amounts of blood products 27 ; moreover, extubation is avoided if the patients received vasopressors or had significant fluid overload. 14 Unfortunately, in these reports, over extubation failure rate, pulmonary complications, and their treatments are not discussed.…”

“…[8][9][10] Development of pulmonary atelectasis after abdominal surgery is very common, due to cephalic displacement of the diaphragm and muscle paralysis. Moreover, systemic inflammatory response after graft reperfusion, transfusion of blood products, positive fluid balance, acute kidney injury, and immunosuppression are additional risk factors for loss of alveolar function and development of ARF after LT. 11,12 The timing of liberation from mechanical ventilation and extubation after LT are debated, 13,14 and the use of pressure support ventilation or CPAP during weaning from invasive MV is still discussed when determining readiness for extubation. 15 In fact, while early extubation exposes patients to the risk of hypoxemia and reintubation, late extubation is associated with prolonged MV and higher risk of ventilator-associated pneumonia.…”