Incidence and indications for reintubation during postoperative care following orthotopic liver transplantation

doi:10.1016/S0952-8180(01)00290-2

Journal of Clinical Anesthesia

Volume 13, Issue 5, August 2001, Pages 377-382

https://doi.org/10.1016/S0952-8180(01)00290-2 Get rights and content

Abstract

Study Objective: To analyze the incidence and indications for reintubation during postoperative care following orthotopic liver transplantation (OLT).

Design: Retrospective chart review.

Setting: Large metropolitan teaching hospital.

Patients: 546 adult liver transplant recipients.

Measurements and Main Results: The medical charts of 546 patients who underwent OLT at our institution between January 1992 and September 1996 were reviewed for the incidence and indications of reintubation throughout primary hospitalization. Eighty-one of 546 patients (14.8%) required one or more episodes of reintubation after OLT. In the majority of cases, reintubation was performed for pulmonary complications (44.6%), followed by cerebral (19.1%) and surgical (14.5%) complications. Cardiac (9.1%) and peripheral neurologic (2.7%) complications were less frequent reasons for reintubation. Overall patient survival, according to the Kaplan-Meier estimates, was 89.9%, 87.5%, 86.5%, and 82.2% after 1, 2, 3, and 5 years, respectively. In patients with one or more episodes of reintubation, overall survival decreased to 62.5% after 1, 2, and 3 years, and to 56.4% after 5 years (p < 0.001).

Conclusions: The main indications for reintubation after OLT were pulmonary, cerebral, and surgical complications. These reintubation events had a considerable influence on the patient’s postoperative recovery, and were associated with a significantly higher rate of mortality, than for OLT patients who did not undo reintubation.

Introduction

Liver transplantation is the established treatment for end-stage liver disease and fulminant hepatic failure.1 This situation has been made possible by an advanced understanding of the pathophysiology and natural history of liver disease, the establishment of multiorgan procurement and preservation techniques, and the development of safer and more potent immunosuppressive drugs. Standardization of surgical techniques and advances in anesthetic management have further contributed to this development.

Despite these and other improvements, postoperative critical care requires meticulous management to counter the adverse impact of secondary organ impairment or postoperative complications. At present, the main postoperative complications are respiratory insufficiency, followed by renal problems, catecholamine-dependent cardiovascular disturbances, hepatic encephalopathy, and infection.

In addition, there is unfortunately an increasing gap between the number of organ donors and possible recipients. During the time that patients are waiting for a liver transplant, liver disease often accelerates, and patients change from a low- to a high-risk profile.2 These increasing risk factors significantly influence the clinical outcome after orthotopic liver transplantation (OLT).

Detailed information is available regarding renal insufficiency, infectious complications, and hepatic allograft dysfunction after liver transplantation.3, 4, 5 However, to date, little information is available on respiratory insufficiency after OLT. We therefore analyzed the incidence and indications for reintubation in patients who underwent OLT at our institution.

Section snippets

Patients

Between January 1992 and September 1996, 572 patients underwent OLT at our institution. Five hundred forty-six patients were included in this retrospective study, from which children were excluded. Forty-two patients underwent retransplantation, and another six patients were transplanted a third time. Demographic data for events and indication of reintubation throughout primary hospitalization, preoperative status, mechanical ventilation before OLT, preoperative and intraoperative details such

Results

There were 110 episodes of reintubation in 81 of the 546 patients (14.8%) (Table 1). Eighteen recipients required two reintubations. We observed another six patients (1.09%) who were mechanically ventilated three times, and two patients (0.36%), each of whom was reintubated a fourth and a fifth time. On 29 occasions (5.3%), tracheostomy was performed for long-term ventilation.

In 16 cases (14.5%), reintubation was due to surgical complications. Abdominal bleeding occurred eight times and

Discussion

The clinical postoperative phase during intensive care management includes endotracheal reintubation in 2% to 19% of the patients.12 This consequence of respiratory impairment substantially affects the recovery process and is associated with increased mortality.12, 13 We examined the incidence and indications of reintubation after OLT in our patient population to learn more about the risk factors for respiratory impairment, accompanied by precautionary measures designed to reduce the need for

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Citation Excerpt :
All patients were eventually extubated. However, reintubation was required in 36% of the patients who had been mechanically ventilated for more than 24 hours and 12% of those who had been intubated for less than 24 hours.9 The most common indications for reintubation were pneumonia, encephalopathy, and surgical bleeding.
Pulmonary Complications of Stem Cell and Solid Organ Transplantation
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Anesthetic practices such as early tracheal extubation facilitate postoperative recovery. Early extubation after liver transplantation has been adopted by some centers in the recent two decades. No universal clinical guidelines are used and questions remain. This review aimed to address the current status of early extubation after liver transplantation.
A literature search of MEDLINE and ISI Web of Knowledge databases was performed using terms such as liver transplantation, early extubation, immediate tracheal extubation, fast tracking or fast track anesthesia and postoperative tracheal extubation. Additional papers were identified by a manual search of the references in the key articles.
Review of the available literature provided an insight into the definition, evolution, advantages and risks of early extubation, and anesthetic techniques that prompt early extubation in liver transplant patients. Early extubation has proved to be feasible and safe in these patients, but the outcomes are still uncertain.
Early extubation after liver transplantation is feasible, safe and cost-effective in the majority of patients and has been increasingly accepted as an option for conventional postoperative ventilation. Comprehensive and individualized evaluation of the patient's condition before extubation by an experienced anesthesiologist is the cornerstone of success. Understanding of its effect on the outcome remains incomplete. In the future, additional trials are required to establish universal early extubation guidelines and to determine its benefits for patients and practitioners.
Noninfectious pulmonary complications of liver, heart, and kidney transplantation
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Early postoperative complications following liver transplantation
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Liver transplantation is a highly successful treatment for patients with end-stage liver disease and acute liver failure. However, serious postoperative complications can significantly compromise patient survival. Complications can be technical, medical, or immunological in nature. The risk of developing early postoperative complications is associated with the patient's preoperative condition, the quality of the donor liver, the quality of the donor and recipient procedure, initial graft function, and perioperative anaesthesiological and intensive care management. The patient's preoperative condition can include gastrointestinal bleeding, acute renal failure, a requirement for cathecholamines or mechanical ventilation, and prolonged encephalopathy for the most detrimental risk factors for developing early postoperative complications. The necessity for prolonged mechanical ventilation or the requirement for reintubation after transplantation can significantly increase the risk of developing pneumonia, sepsis, and multiple organ dysfunction. A decrease in infectious and other complications can be achieved by early postoperative enteral nutition, including the application of probiotics.
Hepatic artery thrombosis after adult liver transplantation
2003, Liver Transplantation
The incidence, clinical presentation, therapeutic options, and outcome of hepatic artery thrombosis (HAT) were analyzed in a series of 1,192 consecutive adult orthotopic liver transplantations (OLTs). HAT after OLT was observed in 30 cases, resulting in an incidence of 2.5%. The incidence of HAT increased 5.76-fold when the donor hepatic artery was reconstructed with an interposition graft to the supraceliac aorta (P < .05). Early HAT (within the first 30 days after OLT) occurred in 14 of these patients (46.7%), whereas in 16 patients (53.3%), HAT occurred beyond 30 days post-OLT. Clinical presentation of HAT ranged from an increase in serum transaminase levels with or without cholestasis to liver abscess and biliary complications, including cholangitis, bile duct stenosis or necrosis, to liver dysfunction and failure. Impairment of graft function was observed in patients with early HAT, whereas biliary tract destruction was seen more often in patients with late HAT. In only 1 patient was HAT clinically asymptomatic. Therapy consisted of recombinant plasminogen lysis with hepaticojejunostomy, liver abscess drainage, endoscopy or surveillance, and surgical thrombectomy. In 14 of 30 patients (46.7%), the occurrence of HAT required re-OLT. Nine patients with HAT died during follow-up; however, only 4 of these deaths were related to HAT, resulting in a mortality rate of 13.3%. Our results indicate that HAT is a rare but serious complication after OLT, requiring re-OLT in almost 50% of patients. In particular, conservative treatment modalities may significantly prolong graft survival, thus postponing re-OLT. (Liver Transpl 2003;9:612-620.)

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^∗: Staff Surgeon

^†: Staff Anesthesiologist

^‡: Medical Student

^§: Professor and Chairman of Anesthesia

^¶: Professor and Chairman of Surgery

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Original contributionIncidence and indications for reintubation during postoperative care following orthotopic liver transplantation

Abstract

Introduction

Section snippets

Patients

Results

Discussion

Risk of perioperative infection after liver transplantationa univariate and stepwise logistic regression analysis of risk factors in 150 consecutive patients

Clin Transplantation

Nephrotoxicity following orthotopic liver transplantation. A comparison between cyclosporine and FK506

Transplantation

Early allograft dysfunction after liver transplantationa definition and predictors of outcome. National Institute of Diabetes and Digestive and Kidney Diseases Liver Transplantation Database

Transplantation

Preoperative and postoperative anesthesiological management in patients undergoing liver or kidney transplantation

Acta Anaesthesiol Scand Suppl

Comparison of FK506- and Cyclosporine-based immunosuppression in primary orthotopic liver transplantation. A single center experience

Transplantation

Aprotinin in orthotopic liver transplantation

Semin Thromb Hemost

The release of cytokines, adhesion molecules, and extracellular matrix parameters during and after reperfusion in human liver transplantation

Transplantation

A randomized, placebo-controlled trial with anti-interleukin-2 receptor antibody for immunosuppressive induction therapy after liver transplantation

Clin Transplant

Liver transplantation in hepatitis B surface antigen positive patients with postoperative long-term immunoprophylaxis

Transplant Proc

Weaning and extubation in the intensive care unit. Clinical or index-driven approach?

Intensive Care Med

Acute complications of endotracheal intubation. Relationship to reintubation, route, urgency, and duration

Chest

Pulmonary complications and disease severity in adult liver transplant recipients

Transplant Proc

Original contribution
Incidence and indications for reintubation during postoperative care following orthotopic liver transplantation