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Extubation in the operating room after pediatric liver transplant: A retrospective cohort study
Harshad G Gurnaney1, Scott D Cook-Sather1, Abraham Shaked2
1Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
Insights
Early extubation after pediatric liver transplant is safe and effective, with over half of patients extubated in the operating room. This strategy significantly reduces intensive care unit and hospital stays.
Area of Science:
- Pediatric Surgery
- Transplantation Medicine
- Critical Care Medicine
Background:
- Early extubation post-liver transplant is increasingly adopted in adult care.
- Pediatric institutions are exploring early extubation strategies for liver transplant recipients.
- Careful patient selection is crucial for minimizing risks associated with early extubation.
Purpose of the Study:
- To determine the early extubation rate in pediatric liver transplant patients.
- To identify clinical factors associated with successful early extubation versus delayed extubation.
- To examine postoperative complications, and intensive care unit (ICU) and hospital length of stay.
Main Methods:
- Retrospective cohort study of infants and children undergoing liver transplantation (July 2011 - December 2014).
- Analysis of early extubation rates and associated clinical factors.
- Comparison of postoperative outcomes between early and delayed extubation groups.
Main Results:
- The early extubation rate was 57.8%, increasing from 42% to 58% during the study period.
- Patients undergoing early extubation were older, more likely to be from home, and less likely to be UNOS status 1A.
- Early extubation was associated with significantly shorter ICU and hospital stays, and no early reintubations or hepatic artery thrombosis.
Conclusions:
- Over half of pediatric liver transplant patients were successfully extubated in the operating room.
- Early extubation is a safe and beneficial strategy for selected pediatric liver transplant recipients.
- This approach can lead to reduced resource utilization and shorter patient recovery times.
Background:
Early extubation immediately following liver transplantation is increasingly common in adult practice. Some pediatric institutions have begun to adopt this strategy. Careful patient selection is essential in minimizing risk.
Methods:
This retrospective cohort study evaluated infants and children who underwent liver transplantation between July 2011 and December 2014. Our primary objective was to determine early extubation rate. Secondary objectives were to identify clinical factors associated with successful early extubation compared with delayed extubation and to examine significant postoperative complications, intensive care unit length of stay, and hospital length of stay.
Results:
The early extubation rate was 57.8% (37/64, confidence interval [CI] 44.8%-70.1%) over this 3.5-year period, increasing from 42% in 2012 to 58% by the end of 2014. The patients in the early extubation group were more likely to be older than the delayed extubation group (mean [SD], 7 [5.3] years vs 3.5 [5.5] years, difference between the mean [95% CI], 3.5 [0.8, 6.2] years); were to have come from home on the day of surgery (78.4% vs 25.9%); and were less likely to be listed as United Network for Organ Sharing status 1A (2.7% vs 25.9%). The early extubation group received less packed red blood cell volume (mean [SD], 9 [13.2] mL/kg vs 40.6 [48.5] mL/kg, difference between the mean [95% CI], 31.6 [95% CI 14.9, 48.3] mL/kg) and fresh-frozen plasma (mean 2.7 [SD 9.5] vs 13.3 [SD15.1], difference between the mean [95% CI], 10.5 [4.4,16.7] mL/kg). None of the patients in the early extubation group required reintubation in the first 24 hours following transplant and none experienced hepatic artery thrombosis. The early extubation group had a shorter average postoperative PICU stay (mean 3.8 [SD 2.1] days vs 17.6 [SD 31.3] days, difference between the mean [95% CI], 9.5 [4.3, 14.7] days) and a shorter postoperative hospital stay overall (mean 10.7 [SD 4.3] days vs 29.7 [SD 43.1] days, difference between the mean [95% CI], 19.1 [8.6, 29.6] days).
Conclusion:
More than half of our pediatric liver transplant patients were successfully extubated in the operating room immediately following surgery. We believe early extubation to be safe when employed in selected subpopulations of pediatric patients undergoing liver transplantation.
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