Fast track anesthesia for liver transplantation: Review of the current practice

Table 1 Early extubation in adult liver transplant recipients

Ref.	Patients (n)	Anesthesia	Criteria for extubation	Findings
Rossaint et al[5]	5/39	Fentanyl infusion, methohexital infusion, thiopental, pancuronium	"According to established criteria" but not clearly delineated
Mandell et al[3]	University of Colorado: 16/67 early extubation; UCSF: 25/106 early extubation	Thiopental, succinylcholine, isoflurane or desflurane, fentanyl, lorazepam, doxacurium	Preoperative: UNOS status 3 or 4; No coexistent disease; Age < 50 yr; No Encephalopathy; Intraoperative: Good donor liver function; < 10 units of red blood cells administered; No vasoactive support at end of surgery; A-a gradient < 150 mmHg	University of Colorado: 0/16 reintubations; UCSF: 2/25 reintubations (hypoventilation/respiratory failure)
Neelakanta et al[7]	35 total patients: 18 extubated in OR; 17 extubated in ICU	Midazolam, thiopental, succinylcholine, isoflurane, fentanyl, morphine, pancuronium	Good nutritional status, no significant cardiac or pulmonary disease, uneventful surgical course, < 3 units of red blood cells transfused, sign of early graft function, normothermia. Decision was made by anesthesiologist after consultation with surgeon	O reintubations for either group. No difference in ICU length of stay; Immediate extubation group had more respiratory acidosis on admission to ICU
Biancofiore et al[1]	365 total patients: Group A: 211 extubated in OR; Group B: 113 extubated < 24 h; Group C: 41 extubated > 24 h	Fentanyl, thiopental, cisatracurium, sevoflurane, remifentanil	Awake, following commands, clinical evidence of neuromuscular reversal, normocarbia, respiratory rate < 25, adequate oxygenation (pulse oximetry > 95% with FiO2 < 0.5), hemodynamic stability	Group A: 2/211 reintubations (surgical bleeding, pneumonia); Group C: 4/41 reintubations (surgical bleeding, pneumonia, hepatic artery thrombosis). Non-invasive ventilation performed in 11/211 Group A and 6/113 in Group B
Glanemann et al[9]	546 total patients: Group 1: 102 extubated in OR; Group 2: 383 extubated < 24 h; Group 3: 61 extubated > 24 h	Fentanyl, methohexital, pancuronium	Hemodynamic stability, normothermia, tidal volume of 5-8 mL/kg, respiratory rate < 20/min, adequate minute ventilation, positive gag reflex, awake and responsive	Group 1: 9/102 reintubated; Group 2: 50/383 reintubated; Group 3: 22/61 reintubated; Survival at 5 yr greatly reduced in Group 3 and in patients whom underwent reintubation. Liver graft reperfusion injury significantly influenced success and time to extubation
Skurzak et al[10]	652 total patients: 575 extubation in OR; 77 nonextubated patients	Varied: Isoflurane or sevoflurane, fentanyl, remifentanil, sufentanil, pancuronim, atracurium, cis-atracurium. Extubated in OR	Conventional criteria used to determine for extubation. Contraindications to early extubation: active bleeding with a need for abdominal packing, preoperative mechanical ventilation, grade 4 encephalopathy, graft dysfunction (acidosis, persistent coagulopathy, hemodynamic instability)	30/575 reintubations within 48 h (surgical interventions, oversedation, pulmonary failure, pulmonary edema, cerebral ischemia, hepatic/renal failure)
Mandell et al[2]	147 total patients: 111 extubated in OR; 23 no attempt at extubation; 13 failed to meet extubation criteria	Thiopental, succinylcholine, isoflurane or desflurane, fentanyl, lorazepam, doxacurium	Awake, following commands, positive gag reflex, tidal volumes > 8 mL/kg, respiratory rate < 20/min, normocarbia, adequate neuromuscular reversal, hemodynamic stability	2/111 reintubations within 48 (portal vein thrombosis, oversedation)

UNOS: United Network for Organ Sharing; ICU: Intensive care unit; UCSF: University of California San Francisco.