Abstract
BackgroundTo investigate the effect of extubation in the operating room (OR) on mechanical ventilation-related adverse outcomes in patients who undergo liver transplantation.MethodsPatients who underwent liver transplantation between January 2016 and December 2019 were included. According to the timing of extubation, patients were divided into OR extubation group and intensive care unit (ICU) extubation group. The propensity score was used to match OR extubation group and ICU extubation group at a 1:2 ratio by demographical and clinical covariates. The primary outcome was a composite of mechanical ventilation-related adverse outcomes, including 30-day all-cause mortality, in-hospital acute kidney injury (stage 2 or 3), and in-hospital moderate to severe pulmonary complications. Secondary outcomes included in-hospital moderate to severe infectious complications, unplanned reintubation rates, ICU and postoperative hospital lengths of stay, and total hospital cost.ResultsA total of 438 patients were enrolled. After propensity score matching, 94 patients were in OR extubation group and 148 patients were in ICU extubation group. Incidence of the composite mechanical ventilation-related adverse outcomes was significantly lower in OR extubation group than ICU extubation group, even after adjusting for confounding factors (19.1% vs. 31.8%; Odds Ratio, 0.509; 95% Confidence Index [CI], 0.274-0.946; P=0.031). The duration of ICU stay was much shorter in OR extubation group than ICU extubation group (median 4, Interquartile range [IQR] (3 ~ 6) vs. median 6, IQR (4 ~ 8); P<0.001). Meanwhile, extubation in the OR led to a significant reduction of total hospital cost compared with extubation in the ICU (median 3.9, IQR (3.5 ~ 4.6) 10000 US dollars vs. median 4.1, IQR (3.8 ~ 5.1) 10000 US dollars; P=0.021). However, there were no statistically significant differences in moderate to severe infectious complications, unplanned reintubation rates, and the length of postoperative hospital stay between groups.ConclusionsAmong patients who underwent liver transplantation, extubation in the OR compared with extubation in the ICU, significantly reduced the primary composite outcome of 30-day all-cause mortality, in-hospital acute kidney injury (stage 2 or 3), or in-hospital moderate to severe pulmonary complications.Trial registrationThe trial was registered at www.clinicaltrials.gov with registration number NCT04261816. Retrospectively registered on 1st February 2020.
Highlights
Liver transplantation has been established as the most effective treatment for acute and chronic end-stage liver diseases [1]
Among patients who underwent liver transplantation, extubation in the operating room (OR) compared with extubation in the intensive care unit (ICU), significantly reduced the primary composite outcome of 30-day all-cause mortality, in-hospital acute kidney injury, or in-hospital moderate to severe pulmonary complications
Patient Population Among 450 patients who were assessed for eligibility between January 2016 and December 2019; 12 patients were excluded from the study for the following reasons: re-transplantation (1 case), severe encephalopathy (3 cases), already intubated before liver transplantation (4 cases), and loss of data (4 cases) (Fig. 1)
Summary
Liver transplantation has been established as the most effective treatment for acute and chronic end-stage liver diseases [1]. Previous studies have suggested that postoperative mechanical ventilation with sedation may decrease surgical stress response and may improve hemodynamic stability, thereby facilitating early recovery in patients after liver transplantation [5]. Mechanical ventilation can provide a direct passageway for pathogens into the lungs, and reduce the mucosal immune barrier function, which may subsequently increase the risk of postoperative pulmonary complications [6, 7]. Increasing evidence showed that mechanical ventilation, through reducing cardiac output and increasing central venous pressure and diminishing renal blood flow [8], is associated with a threefold increase in the risk of acute kidney injury (AKI) [9]. To investigate the effect of extubation in the operating room (OR) on mechanical ventilation-related adverse outcomes in patients who undergo liver transplantation
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