Pro: Early Extubation After Liver Transplantation

Abstract

HE DECISION TO extubate a patient at the conclusion of surgery or continue ventilatory support generally rests on 2 conditions: the patient’s ability to achieve standard physiologic criteria and the clinicians’ ability to predict early postoperative adverse events. The standard criteria for extubation at the end of surgery and protocols that direct elective ventilatory weaning have good predictive value to identify those patients who will suffer from primary respiratory failure. 1,2 These protocols are universally accepted standards of care for deciding whether to terminate mechanical ventilation. But, they do not assess if other adverse events could occur that can lead to respiratory failure. Adverse events that cause respiratory failure make extubation impractical even if patients fulfill standard physiologic criteria. The decision to extubate is highly influenced by what risk a physician thinks a patient has of experiencing an adverse event that could cause respiratory failure. Because objective variables such as patient and surgical characteristics do not always predict adverse events, the decision to extubate often includes the subjective impression of the physician. Therefore, differences in physician judgment fuel the ongoing debate about the “safety” of early extubation for large procedures such as cardiac surgery, major vascular reconstruction, and liver transplantation. This brief review examines this controversial issue in liver-transplant recipients. The authors summarize the current evidence that supports the broader adoption of early extubation for liver-transplant recipients by showing that early extubation does not negatively affect patient outcome and is cost effective. Physicians often elect to continue mechanical ventilation in patients who have large or complicated procedures because these patients experience a greater number of adverse events that would increase their risk of respiratory compromise. However, routine ventilation treats each individual as though they had an identical risk of experiencing an adverse outcome. The use of routine postoperative ventilation for a particular type of surgery or situation then forces all patients into a single care plan. It actively prevents patients from recovering at a rate faster than dictated by the protocol. Many physicians argue that elective postoperative ventilation provides a longer period of time in which a patient can be optimized and assessed for extubation. They presume that this will prevent complications and improve patient outcome. This type of reasoning underlies the belief that prophylactic postoperative ventilation is inherently safer than early extubation.3 The lack of evidence showing routine ventilation improves outcome conflicts with the evolving demand for evidencebased protocols. Evidence-based protocols are designed to efficiently allocate resources while controlling cost. This approach demands that unnecessary medical interventions are eliminated and that objective evidence is used to allocate resources. How physicians chose to manage postoperative ven