Early extubation practices following liver transplantation: a review of the literature

Abstract

Background: Early extubation and fast-tracking after liver transplantation (LT) has become increasingly popular worldwide. It has been suggested that avoidance of prolonged intubation has beneficial effects on postoperative outcome in general, and on pulmonary complications and liver graft function in particular, but literature data are inconsistent.

Objectives: Our aim was to evaluate the definition, incidence, outcomes, anesthetic management and criteria for immediate or early extubation after LT.

Methods: A literature search in Pubmed, Medline and Embase was performed using the following MeSH terms: liver transplantation, early extubation, fast-tracking, enhanced recovery.

Results: The definition of early extubation ranges between immediate extubation at the end of surgery and extubation within 8 hours after surgery. There is great variability between centers for the incidence of early extubation. Several publications show that it is feasible and safe to extubate selected patients immediately or within a few hours after liver transplantation, but the beneficial effects on postoperative outcome remain controversial. In some centers immediate extubation reduced the length of stay in the intensive care unit (ICU) and the total hospital length of stay, and bypassing the ICU reduced the cost. Several factors precluding a successful immediate or early extubation after LT have been identified, but most centers do not have a standardized protocol to select good candidates. In contrast with standardized enhanced recovery after surgery protocols for major procedures, there is no standardized anesthetic management for fast-tracking after LT.

Conclusions: Immediate or early extubation after LT is feasible, safe, and possibly associated with a better postoperative outcome in selected patients. A criteria-based, center-specific, multidisciplinary designed protocol could result in more liver recipients benefitting from immediate or early extubation. Prospective, well-designed trials are warranted to improve immediate or very early extubation practices after LT.