TRACHEAL EXTUBATION AFTER ORTHOTOPIC LIVER TRANSPLANTATION.

Abstract

O371 Aims: Advances in anesthetic management, surgical techniques and patient preparation, in addition to improved postoperative care and reported advantages of early postoperative tracheal extubation of liver recipients, encouraged us to extubate selected recipients at the end of the operation1. The aim of the present study was to evaluate perioperative data of liver transplant recipients who were extubated immediately at the end of surgery. Methods: We retrospectively reviewed perioperative data of patients who underwent Orthotopic Liver Transplant (OLT) at Hospital Israelita Albert Einstein between January 2002 and March 2004. In this period a total of 204 adult OLT were performed. Exclusion criteria for extubation were defined as: age > 60 years old, preoperative cerebral encephalopathy, obesity (body mass index > 34kg/m2), previously intubated in the ICU, packed red blood cell transfusion > 10 U, marginal donors and vasoactive support at end of surgery2,3. Patients in the study group were separated into 3 groups: Group 1: Extubated in the OR; Group 2: Extubated less than 12 hours in the ICU; Group 3: Extubated longer than 12 hours in the ICU. Venovenous bypass or temporary porto-caval shunting were not applied in a routine basis (only 2 cases). Surgical technique consisted of piggyback with caval preservation (170 cases), with the remaining cases having conventional caval reconstruction. Anesthesia technique consisted of propofol, fentanyl and cisatracurium. Intermittent boluses of fentanyl (50-100g) as required or remifentanil infusion (0.05-0.2g/kg/min) along with isoflurane (0.4-1.2% end-tidal concentration) in air-oxygen (FiO2 0.4-0.5) and/or propofol (50-100ug/kg/min). Patients were mechanically ventilated (Servo ventilator 900 C-Siemens) with a tidal volume of 810 ml/kg, a respiratory rate of 10-16 breaths/min adjusted to maintain end-tidal carbon dioxide (ETCO2) of 32-35 mmHg. Standard anesthesia monitoring with radial artery and pulmonary artery catheter, electrocardiogram (ECG), pulse oxymeter (SpO2), capnogram and anesthetic gas concentration and urine output were used in all patients. Results: Ninety patients matched the exclusion criteria, leaving 114 patients in the study groups. In group 1, twenty-nine (25%) patients were extubated immediately after surgery. Reintubation or mechanical ventilation were not required in the ICU in this group. The remaining 85 patients (75%) were extubated in the ICU. Group 2 comprised of 68 patients (59%), with a mean extubation time of 4.8±2.9hs. Group 3 comprised of 17 patients (15%) who required mechanical ventilation for more than 12 h (24%), with a mean extubation time of 64.58±59.20. There was no statistical difference among groups in terms of age, sex and blood transfusion requirements. Conclusions: Advances in surgical and anesthetic technique and management allowed safe early extubation. In this series most of the patients were safely extubated in less than 5 hours. Fast tracking these low risk patients to a regular ward is a possibility and should be considered in a future study.