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.

Table 2 Arguments for/against fast track anesthesia

Pro	Con
Improved graft blood flow	Need for recovery after surgical stress
Decreased complications from mechanical ventilation	Time to optimize cardiopulmonary parameters
Patient comfort	Chance of failed extubation
Less chest radiographs	Absence of large prospective studies showing benefit
Improved resource utilization	Chance of reoperation
Cost containment