Tracheostomy Post Liver Transplant: Predictors, Complications, and Outcomes

Abstract

Background Liver transplant (LT) patients have an increased risk of postoperative respiratory failure requiring tracheostomy. This study sought to characterize objective clinical predictors of tracheostomy. Material/Methods The records for 2017 LT patients at a single institution were reviewed. Patients requiring tracheostomy were first compared with all other patients. A case-control subgroup analysis was conducted in which 98 tracheostomy patients were matched with 98 non-tracheostomy LT patients. For the case-control study, muscle mass was assessed using preoperative computed tomography scans. Results Among 2017 LT patients, 98 required tracheostomy (5%), with a 19% complication rate. Tracheostomy patients were older and had a higher model for end-stage liver disease score, a lower body mass index (BMI), and a greater smoking history. Tracheostomy patients had a longer hospital stay (45 vs. 10 days, P <0.001) and worse 1-year survival (65% vs. 91%, P <0.001). Ten-year Cox regression patient survival for tracheostomy patients was significantly worse (32% vs. 68%, P <0.001). In the case-control analysis, respiratory failure patients were older ( P <0.01) and had a lower BMI ( P =0.05). They also had a muscle mass deficit of −39% compared with matched LT controls ( P <0.001). No significant differences were seen with pre-LT total protein or albumin or with forced expiratory volume in 1 s divided by forced vital capacity (FEV1/FVC) values. Conclusions Predictors for respiratory failure requiring post-LT tracheostomy include higher model for end-stage liver disease score, older age, lower BMI, greater smoking history, and worse sarcopenia. Patients requiring tracheostomy have dramatically longer hospital stays and worse survival.

The use of tracheostomy to support critically ill children receiving orthotopic liver transplantation: a single‐center experience

“…14,17,30,39,40 We report a 21% 1-year mortality among patients who required tracheostomy after LT. Though higher than overall 1-year morality after LT in our institution, it is consistent with the previous pediatric study by Mack et al 23 and adult post-LT studies 26,27 and much lower when compared to mortality of ~50% reported in critically ill immunosuppressed children with multi-system organ failure. 41 In a separate cohort of 5 patients with ESLD and preexisting tracheostomy for chronic respiratory failure, we show a survival rate of ~80%.…”

“…The incidence of post‐LT tracheostomy in our cohort is 7%. This is similar to the adult studies which report an incidence between 5–9% 26,27 . In adults, incidence of lung injury and respiratory failure in liver transplant recipients is higher than heart and kidney transplant recipients, attributed most likely due to frailty and basal deconditioning in patients with chronic liver failure compared to chronic heart or kidney failure 28 .…”

“…This is similar to the adult studies which report an incidence between 5-9%. 26,27 In adults, incidence of lung injury and respiratory failure in liver transplant recipients is higher than heart and kidney transplant recipients, attributed most likely due to frailty and basal deconditioning in patients with chronic liver failure compared to chronic heart or kidney failure. 28 The leading indication for tracheostomy in our study was the need for prolonged MV and inability of the child to maintain adequate gas exchange without invasive positive pressure ventilation despite numerous attempts to extubate to noninvasive modalities.…”

Subjective Assessment of Motor Function by the Bedside Nurses in Mechanically Ventilated Surgical Intensive Care Unit Patients Predicts Tracheostomy

“…In our study, we controlled for known predictors of tracheostomy such as age, APACHE II score, comorbidities, metabolic disturbances, and neurological dysfunction (level of sedation and delirium risk). 8,[10][11][12] This suggests that muscle weakness is not only an indicator of the severity of disease but also an independent predictor of the inability to protect the airway and of diaphragmatic dysfunction for an extended period of time.…”

“…A priori defined confounding variables were chosen based on available literature and clinical plausibility 8,[10][11][12][13][14][15] : age, history of home oxygen dependency, history of congestive heart failure, fluid balance within 24 h prior to extubation, highest blood urea nitrogen and lowest hemoglobin within 24 h prior to extubation, number of spontaneous breathing trials performed prior to extubation, duration of invasive mechanical ventilation and mean minute ventilation. To examine potential added value of this subjective nursing assessment to other routine critical care risk assessments, Acute Physiology and Chronic Health Evaluation II (APACHE II), delirium risk (confusion assessment method for the intensive care unit (CAM-ICU)) and sedation/agitation level assessment (based on Richmond Agitation-Sedation Scale (RASS)) within 24 h prior to extubation were included in the primary multivariable regression model (supplemental material 1, section IIc).…”