Avoiding Stay in The Intensive Care Unit After Liver Transplantation: A Score To Assign Location of Care.

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Background: Hemodynamic, respiratory and metabolic support in the intensive care unit (ICU) immediately after liver transplantation (LT) is considered routine. Since 2002, select LT recipients in our program have been transferred from operating room to post-anesthesia care unit for recovery and extubation of trachea with transfer to the ward, completely eliminating an ICU stay. Developing a reliable method to determine which patients may be suitable for for fast-tracking would be of practical benefit to centers considering adopting this practice. The aim of this study was to create a fast tracking probability score that could be used to predict successful assignment of care location after LT. Methods: Recipient, donor and operative characteristics were assessed for association with fast-tracking using multivariable logistic regression models. Factors that were independently associated with fast-tracking were used to create a fast-tracking probability score. Results: Between 2003 and 2010, we performed a total of 1547 LT. Of the 1296 LT that met inclusion criteria, 704 (54.3%) were fast-tracked to the surgical ward, and 592 (45.7%) were directly admitted to the ICU after LT. Based on 9 readily available variables (recipient age, BMI, recipient gender, MELD, pre-LT length of hospital stay, transfusion amount, operative time, vasopressor use during last hour of LT, and retransplant status) at the time LT, we created a scoring system that classified patients according to the likelihood of being fast-tracked to the surgical ward, with an area under the ROC curve of 0.790 (95% CI: 0.765 - 0.816). Validation of the score in a separate cohort of 323 LT revealed area under the ROC curve of 0.834. With a median follow-up length of 5.2 years (Range: 1 day - 9.7 years), both overall patient survival (RR: 0.75, 95% CI: 0.60 - 0.96, P=0.020) and graft survival (RR: 0.78, 95% CI: 0.62 - 0.98, P = 0.032) were significantly better for fast-tracked patients compared to patients who went to ICU. Our center has developed a fast-track practice that has been shown to be safe and effective in delivering high quality care in the post-operative setting. We propose a scoring tool that can be used along with clinical judgment to aid in determining the appropriate location of care immediately after LT.