Intraoperative predictors of early tracheal extubation after living-donor liver transplantation

Abstract

BackgroundProlonged mechanical ventilation after liver transplantation has been associated with deleterious clinical outcomes, so early tracheal extubation posttransplant is now increasing. However, there is no universal clinical criterion for predicting early extubation in living-donor liver transplantation (LDLT). We investigated specific predictors of early extubation after LDLT.MethodsPerioperative data of adult patients undergoing LDLT were reviewed. "Early" extubation was defined as tracheal extubation in the operating room or intensive care unit (ICU) within 1 h posttransplant, and we divided patients into early extubation (EX) and non-EX groups. Potentially significant (P < 0.10) perioperative variables from univariate analyses were entered into multivariate logistic regression analyses. Individual cut-offs of the predictors were calculated by area under the receiver operating characteristic curve (AUC) analysis.ResultsOf 107 patients, 66 (61.7%) were extubated early after LDLT. Patients in the EX group showed shorter stays in the hospital and ICU and lower incidences of reoperation, infection, and vascular thrombosis. Preoperatively, model for end-stage liver disease score, lung disease, hepatic encephalopathy, ascites, and intraoperatively, surgical time, transfusion of packed red blood cell (PRBC), urine output, vasopressors, and last measured serum lactate were associated with early extubation (P < 0.05). After multivariate analysis, only PRBC transfusion of ≤ 7.0 units and last serum lactate of ≤ 8.2 mmol/L were selected as predictors of early extubation after LDLT (AUC 0.865).ConclusionsIntraoperative serum lactate and blood transfusion were predictors of posttransplant early extubation. Aggressive efforts to ameliorate intraoperative circulatory issues would facilitate successful early extubation after LDLT.

Predictive score for immediate extubation after liver transplantation

“…The incidence of immediate extubation (32.1%) was noticeably lower than those reported by other studies (58% to 83.5%) 1,2,4,5 . However, a subgroup analysis indicated that the incidence rose by 56.4% from 2011 to 2016, which is comparable with the findings of other studies.…”

“…Orthotopic liver transplantation (OLT) has been used to treat acute and chronic end‐stage liver disease for nearly five decades 1 . In the past, post‐liver transplant patients required mechanical ventilation with sedation or analgesia for more than 24 h due to prolonged surgery, massive blood transfusion, and high‐volume fluid administration 2 . Current evidence, however, suggests that positive pressure ventilation may have deleterious effects on graft outcomes due to liver congestion from high venous pressure, 1,3,4 suggesting that patients may benefit from earlier withdrawal from mechanical ventilation.…”

“…Many previous studies reported incidences of immediate extubation ranging from 58% to 83.5% 1,2,4,5 with various significantly associated factors, including preoperative patients’ status (Model for End‐stage Liver Disease [MELD] score, CHILD status), 1,6 the amount of intraoperative packed red cells (PRC) transfusion, 2,5,7–9 and a low‐dose inotropic agent requirement at the end of surgery 2,5–7 Most of the studies presented data demonstrating that the early extubation practice provided economic benefits by reducing hospital stays and intensive care unit (ICU) admissions without compromising patient condition or safety 2,4,10 . Nonetheless, many anesthesiologists are still reluctant to extubate patients immediately after this major operation.…”

Immediate versus conventional postoperative tracheal extubation for enhanced recovery after liver transplantation

“…F–M in Appendix 2). In addition, regarding Child C status (%), one study [ 27 ] adopted the data form of Child B+C %, however, it did not change the pooled effect as removed from the main analysis (Fig. N in Appendix 2).…”

“…All the studies used patients’ medical records for their analyses (Table 2 ). The IPTE exposures were inconsistent across those studies, 7 [ 9 , 20 – 23 , 25 , 27 ] studies described the detailed time interval, but 3 [ 24 , 26 , 28 ] studies failed to give the detailed description. We sparingly pigeonholed the 3 ones as “< 8 hours ν control,” with the risk of adjustment questionable.…”