Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society
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Randomized Controlled Trial Comparative Study Clinical Trial
Fast track anesthesia for liver transplantation reduces postoperative ventilation time but not intensive care unit stay.
Fast tracking is an approach to health care delivery that emphasizes the efficient use of resources. This investigation was designed to determine whether shorter-acting drugs and different drug administration practices reduce the length of time for which patients require mechanical ventilation and intensive care after liver transplantation. After obtaining Institutional Review Board approval and informed consent, we randomized 80 consecutive patients (>17 years) undergoing liver transplantation to receive either our traditional anesthetic (thiopental, pancuronium, 50 microg/kg fentanyl), or fast track anesthetic (propofol, cisatracurium, 20 microg/kg fentanyl). ⋯ However, there was no difference in length of intensive care unit stay. Five patients required reintubation (two patients given the traditional anesthetic, three given the fast track anesthetic). We conclude that a fast track approach to anesthetic care reduces the requirement for postoperative mechanical ventilation, but does not reduce intensive care unit stay after liver transplantation.
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Part 1 of our report, presented in the same issue of the Journal, shows that immediate postoperative extubation and direct transfer to the surgical ward is safe and reduces reliance on the intensive care unit in most liver transplant recipients. However, there is no method to preoperatively predict which patients will need ventilatory support after surgery. To address this issue, we examined the relationship between perioperative patient attributes and extubation outcome in patients entered into our immediate postoperative extubation study from 1996 to 1998. ⋯ Female sex (P =.02), BMI of 32 or greater (P =.015), portosystemic shunt (P =.022), and encephalopathy (P =.041) were associated with no attempt by the physician to extubate, whereas encephalopathy (P =.01) and BMI of 34 or greater (P =.002) were associated with failure to meet criteria for postoperative extubation (described in part 1 of this study). We conclude there are limited factors that predict an increased risk for postoperative respiratory failure in liver transplant recipients. Our results indicate that physicians are conservative in their approach to extubation immediately after surgery, and sole reliance on physician judgment to determine suitability for postoperative extubation leads to unnecessary use of postoperative cardiopulmonary support.
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Postoperative ventilation and admission to the intensive care unit (ICU) is the standard of care in liver transplantation and comprises a significant proportion of transplantation costs. Because immediate postoperative extubation has been reported previously in a selected group of liver transplant recipients, we questioned whether this protocol could be extended to a larger group of patients. We also sought to determine the proportion of patients extubated immediately after surgery that could be transferred to the surgical ward without intervening ICU care. ⋯ A learning curve detected during the 3-year study period showed that attempts to extubate increased from 73% to 96% and triage to the surgical ward increased from 52% to 82% without compromising patient safety. The use of this protocol in our institution resulted in a 1-day reduction in ICU use in 75.5% of study subjects. We therefore conclude that the majority of liver transplant recipients can be extubated safely and admitted to the surgical ward after liver transplantation surgery, thus decreasing the cost associated with ICU care.