Role of Early Extubation in Decreasing Morbidity and Mortality in Liver Transplantation.

BACKGROUND: Early extubation is a fundamental element integrated into enhanced recovery protocols in orthotopic liver transplantation (OLT). The aim is to evaluate whether early extubation influences short- and medium-term postoperative morbidity and mortality. METHODS: A cohort of 209 patients who underwent OLT in a tertiary hospital in a period from January 2016 to December 2018 were retrospectively analyzed. Patients were divided into 2 groups: group 1: early extubation in the intensive care unit and group 2: delayed extubation. Mortality is compared between both groups in the first month and first and third year. Postoperative morbidity was also compared. RESULTS: Patients in group 1 (n = 165, 79.9%) presented, with statistical significance, lower mortality at 1 month, 1 year, and 3 years; shorter duration of admission to the critical care unit and of hospital stay; lower incidence of surgical reoperation and retransplant; lower rate of transfusion of blood products; fewer pulmonary, digestive, neurologic, cardiologic, hemodynamic, kidney, surgical, infectious, metabolic, thrombotic, vascular, and graft complications; less need for kidney replacement therapy; less refractory ascites; and greater infectious risk. However, no statistically significant differences were found in the need for hospital readmission; in biliary, endocrine, nutritional, hematologic, thrombotic, and hematologic complications; or in graft rejection. In group 1, 6.6% of patients required reintubation. In group 2, 97% of patients could be extubated during the first week; 7.8% required noninvasive mechanical ventilation type bilevel positive airway pressure and 8.1% high flow. Only 2.8% of patients required tracheotomy. CONCLUSIONS: The role of early extubation seems key to improve outcomes in OLT because it reduces the incidence of multiple complications and mortality, with low reintubation rates. It is a feasible and safe procedure.

Case Report of a Patient Treated With Acenocumarol Awaiting Orthotopic Liver Transplant: Perioperative Coagulation Management and Risk for Hepatic Artery Thrombosis.

BACKGROUND: End-stage liver disease is associated with a concomitant reduction of pro- and anticoagulant factors that typically leads to rebalanced hemostasis. This rebalanced hemostasis can be easily disturbed, encountering both hemostasis-related bleeding episodes and thrombotic events. METHODS: This article reports a case of a 52-year-old man diagnosed with portal vein thrombosis and treated with Acenocumarol. The patient received ortothopic liver transplant. The preprocedure international normalized ratio was 3.5. A transfusion of 2000 units of prothrombin complex concentrate was indicated by Hematology. RESULTS: Repeated intra- and postoperative hepatic artery thrombosis resulted in graft loss and patient retransplantation in first 24 hours. CONCLUSIONS: The new concept of rebalanced hemostasis in these patients forces us to change our clinical decisions in preoperative coagulation management, avoiding old practices based on the traditional model such as transfusion guided by international normalized ratio and platelet count, among others that will be analyzed in present work.

Hepatic Artery Thrombosis After Orthotopic Liver Transplant: Experience in the Last 10 Years.

BACKGROUND: Hepatic artery thrombosis (HAT) is the second cause of graft failure, after primary disfunction. It has a significant morbidity, with a retransplant and mortality rate in early hepatic artery thrombosis of 50%. The incidence of this event goes from 2% to 9% in the adult population. METHODS: The objective is to assess the incidence of HAT in a third-level hospital. The study design is an observational retrospective study, collecting data of the transplant recipient from 2010 to 2020. RESULTS: Incidence of HAT was 5.33% (39/732). A statistical difference was found with the blood intraoperative administration (P = .002) and with the presence of anatomic abnormalities in the hepatic artery between the HAT and the non-HAT group. We did not find any statistical difference with portal thrombosis (P = .73) between the groups. CONCLUSIONS: HAT is a fatal complication after an orthotopic liver transplant, which can lead to graft loss and even recipient death. For these reasons, we should early identify risk factors associated with this event early and try to minimize them to avoid the devastating consequences.