Safety and Feasibility of Early Extubation in Liver Transplantation: Experience in 1555 Patients

Conrad Lacom; Rishi P Kothari; Nicholas V Mendez; Alessandro Galli; Garrett R Roll; Michael P Bokoch; Matthieu Legrand; Dieter Adelmann

doi:10.1097/TP.0000000000005356

Safety and Feasibility of Early Extubation in Liver Transplantation: Experience in 1555 Patients

Transplantation. 2025 Feb 14. doi: 10.1097/TP.0000000000005356. Online ahead of print.

Authors

Conrad Lacom^{1

2}, Rishi P Kothari^{1

3}, Nicholas V Mendez¹, Alessandro Galli^{1

4}, Garrett R Roll⁵, Michael P Bokoch¹, Matthieu Legrand¹, Dieter Adelmann¹

Affiliations

¹ Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA.
² Division of General Anesthesia and Intensive Care Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Medical University of Vienna, Vienna, Austria.
³ Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA.
⁴ Dipartimento di Emergenza, Azienda Socio Sanitaria Territoriale Papa Giovanni XXII, Urgenza e Area Critica, Bergamo, Italy.
⁵ Department of Surgery, University of California, San Francisco, San Francisco, CA.

PMID: 39948722
DOI: 10.1097/TP.0000000000005356

Abstract

Background: Early extubation after liver transplantation can decrease cost and intensive care unit lengths of stay, but its adoption remains limited because of safety concerns. We assessed the feasibility and safety of early extubation at a liver transplant center with a high early extubation rate. We analyzed subgroups of high-risk patients, including high model for end-stage liver disease-sodium (MELD-Na) score, high intraoperative blood loss, and patients undergoing simultaneous liver-kidney transplantation.

Methods: We included all adult liver transplantations performed at a single center between June 2012 and July 2022. Patients were divided into 2 groups: (1) those extubated early (ie, in the operating room or within the first hour of intensive care unit admission) and (2) those who underwent delayed extubation. The primary outcome was reintubation within 48 h after early extubation. Rates of early extubation were analyzed separately for quartiles of MELD-Na score and intraoperative blood loss.

Results: Of 1555 patients, 969 (62%) were extubated early. Of these, 31 patients (3.2%) required mechanical ventilation within 48 h postoperatively: 11 patients (1.1%) were reintubated for respiratory failure and 20 (2.1%) remained intubated after reoperation. There was no difference in postoperative pneumonia between the groups (P = 0.059). Early extubation rates inversely correlated with the quartiles of MELD-Na score and estimated blood loss. In the highest quartile for MELD-Na (>34) and estimated blood loss (>5 L), 34% of patients were extubated early.

Conclusions: Early extubation of properly selected patients after liver transplantation is safe and associated with a low rate of reintubation, even among select groups of high-risk patients.