Fast tracking in liver transplantation. Immediate postoperative tracheal extubation: feasibility and clinical impact

Increased survival rates after orthotopic liver transplantation (OLT) in patients with end-stage liver disease have become possible due to an advanced understanding of the pathophysiology of liver disease, the establishment of multiorgan procurement and preservation techniques, and the development of safer and more potent immunosuppressive drugs. In addition, standardisation of surgical techniques and advances in anaesthetic management have contributed significantly to this development. The up-to-date concept of improving patient outcome following OLT includes a fast track approach in selected patient populations, which may shorten ICU and/or hospital stay and reduce costs. In particular, immediate postoperative extubation has been identified as an excellent tool to achieve both improved clinical results and a reduced drain on financial resources. Studies on fast tracking protocols have shown clearly that prolonged mechanical ventilation following surgery is no longer justified in the majority of patients. On current evidence at least 70-80% of transplant recipients can be extubated immediately following surgery. The incidence of reintubation is not increased hereafter when compared to patients extubated later. However, special attention should be focused on liver transplant recipients in poor clinical condition at the time of OLT, undergoing complicated surgery, or receiving liver grafts with severe preservation injury. These patients might not be eligible for fast tracking protocols and may be at increased risk of prolonged postoperative mechanical ventilation.