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Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated
Matthew A Goldstein1, Joelle Karlik2,3, Pradip P Kamat1
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA.
Insights
Immediate extubation in pediatric liver transplant patients is safe and effective, improving recovery. This approach reduced complications, infections, and mortality, with most patients successfully extubated without reintubation.
Area of Science:
- Pediatric Surgery
- Transplantation Medicine
- Critical Care Medicine
Background:
- Immediate extubation is increasingly utilized in pediatric liver transplantation.
- Limited data exist on identifying suitable candidates and its impact on recovery.
Purpose of the Study:
- To evaluate the feasibility and outcomes of immediate extubation in pediatric liver transplant recipients.
- To identify factors associated with successful immediate extubation and its effect on patient recovery.
Main Methods:
- Retrospective review of pediatric liver transplant patients (2015-2021).
- Comparison of preoperative status and intraoperative management between immediately extubated and non-extubated groups.
- Analysis of outcomes including reintubation, infection, length of stay, and mortality.
Main Results:
- 121 of 173 patients (69.9%) underwent immediate extubation.
- Immediate extubation was associated with older age, lower PELD/MELD scores, and reduced transfusion volumes.
- Significantly decreased high flow nasal cannula (HFNC) use, postoperative infection, mortality, and pediatric intensive care unit (PICU) length of stay (LOS) were observed in the extubation group.
Conclusions:
- Immediate extubation is achievable in approximately 70% of pediatric liver transplant recipients, with a low reintubation rate (2.5%).
- Successful immediate extubation correlates with reduced HFNC requirements, lower infection rates, shorter LOS, and decreased mortality.
- Proper patient selection and a multidisciplinary approach enable improved recovery post-pediatric liver transplantation without increased respiratory complications.
Background:
Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery.
Methods:
This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality.
Results:
A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant.
Conclusions:
Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.
