Immediate post-operative extubation decreases pulmonary complications in liver transplantation recipients

Background: Patients undergoing liver transplantation (LT) have traditionally remained intubated in the early postoperative period. Recently, early extubation and fast track anesthesia (strategy for rapid recovery from anesthesia) have gained popularity as they facilitate early recovery and decrease complications associated with prolonged mechanical ventilation. The aim of our study was to investigate the predictive factors for successful immediate post-operative extubation and to understand the clinical impact of this practice on the postoperative course. Methods: This is a single-center, retrospective study of recipients that underwent LT between January 2016 and May 2017. The study was approved by our institutional review board after which data was obtained by electronic chart review. All LT patients were included except for liver-kidney transplants, living donor transplants, and retrasnplant patients. Donor and recipient characteristics were balanced by propensity score matching (PSM) model between the immediate and late extubation groups and postoperative outcomes were analyzed. Primary end points assessed included length of intensive care unit (ICU) stay, length of hospital stay, respiratory complications, and 90-day graft outcomes. Results: A total of 131 patients were eligible for this study and they were all shifted to ICU post transplant. Forty two (32.1%) were extubated at the end of LT surgery (immediate extubation group), 4 (9.5%) of whom were reintubated in the first week. On multivariable analysis, a chance of immediate extubation decreased by 6.4% per 1 unit of MELD score increase (OR=0.94, P=0.016), and by 89% in donation after cardiac death donors (OR=0.09, P=0.026). Operative time and anhepatic time were significantly shorter and blood transfusion requirement was significantly lower in the immediate extubation group. A total of 76 patients (38 patients in each group) were matched in the PSM model. Immediate extubation group showed a significantly lower rate of pulmonary complications at 3 months (10.5% vs. 36.8%, OR=0.202, P=0.011). Length of ICU and hospital stay were shorter in the immediate group, but this difference was not significant (ICU: 2 vs. 3 days, P=0.093, hospital stay: 8 vs. 9 days, P=0.149). Ninety day-graft survival rates were similar in both groups (97.4% vs. 97.4%, P=0.57). Conclusion: Immediate extubation after LT may decrease risk of early pulmonary complications. Because reintubation was required in close to 10% of those who underwent immediate extubation, close post-operative monitoring in the ICU is important