**3.6 Early-extubation (fast-tracking)**

In general, fast tracking of a patient refers to improvement in quality of care, short length of stays in ICU and hospital and reduced costs of total treatment. Prolonged mechanical ventilation is no longer desired, for a group of patients devoid of risk factors, following orthotopic liver transplantation (OLT). 'Fast-tracking' defined as tracheal extubation at the conclusion of surgery before leaving the operating room, varies widely among the centers for OLT recipients. In liver transplantation the aim is rapid progress from preoperative preparation throughout the surgery and early discharge from hospital. Because of the nature of this procedure; awaiting recipients for a cadaver liver donor graft, fast-tracking contributes to intra- and post-operative surgical and anesthesiological strategies; meaning generally a reduction in the postoperative ventilation time (Glanemann, 2007).

In recent years there is a gradual increase in the number of early extubated recipients approaching to approximately 70-80% (Forraz-Neto et al, 1999; Park et al, 2000; Biancofiore et al, 2005; Salizzoni et al, 2005). Postoperative positive airway pressure ventilation combined with sedation has been known to decrease surgical stress response, improve haemodynamic stability and facilitate early recovery; however leading to elevated intrathoracic pressures it causes an increase in pulmonary vascular resistance which in turn rises right ventricular afterload. The possible associated tricuspit regurgitation there may occur venous congestion in the graft (Jullien et al, 1995). On the other hand, spontaneous breathing has been shown to reduce intrapleural pressures, improving venous return and hepatic blood flow; leading to a better recovery (Kaisers et al, 1995). Fast-tracking combined with the restrictive fluid management have been shown to result in rapid recovery (Rossaint et al, 1990).

Fast-tracking of the patients with liver transplantation is usually safe and well tolerated; postoperative mechanical ventilation is no longer required for the majority of patients who are devoid of risk factors (Glanemann, 2007). However, as the Model for end-stage liver disease (MELD)-score based organ allocation system has been introduced, the number of patients to be the candidates for fast-tracking is decreased; because it has been shown that early extubation also has its own complications including postoperative ventilatory failure resulting in impaired oxygen delivery to the new graft and reintubation for early surgical complications such as bleeding, bile leak, thrombosis or retransplantation (Mandell et al, 2007).

**Risk factors** for prolonged mechanical ventilation after liver transplantation has been described in a statistical analysis. Acccording to this analysis, encephalopathy and a body mass index >34 were significantly associated with failure, thus cannot be extubated in the operating room. Primary graft dysfunction, renal failure, cardiovascular failure, neurological

patients diagnosed with CPM by neurological imaging findings (Lee et al, 2009). Patients with hyponatremia can be successfully operated but they are at increased risk of cerebral demyelination syndromes. In one report rapid correction of hyponatremia causing a perioperative rise of 21-32 Meq/L in the serum sodium were associated with central pontine myelinolysis, while an increase of 16 mEq/L was not (Wszolek et al, 1989). The first step in management of hyponatremia is determination of the patient's volume status (Gines P &

In general, fast tracking of a patient refers to improvement in quality of care, short length of stays in ICU and hospital and reduced costs of total treatment. Prolonged mechanical ventilation is no longer desired, for a group of patients devoid of risk factors, following orthotopic liver transplantation (OLT). 'Fast-tracking' defined as tracheal extubation at the conclusion of surgery before leaving the operating room, varies widely among the centers for OLT recipients. In liver transplantation the aim is rapid progress from preoperative preparation throughout the surgery and early discharge from hospital. Because of the nature of this procedure; awaiting recipients for a cadaver liver donor graft, fast-tracking contributes to intra- and post-operative surgical and anesthesiological strategies; meaning

In recent years there is a gradual increase in the number of early extubated recipients approaching to approximately 70-80% (Forraz-Neto et al, 1999; Park et al, 2000; Biancofiore et al, 2005; Salizzoni et al, 2005). Postoperative positive airway pressure ventilation combined with sedation has been known to decrease surgical stress response, improve haemodynamic stability and facilitate early recovery; however leading to elevated intrathoracic pressures it causes an increase in pulmonary vascular resistance which in turn rises right ventricular afterload. The possible associated tricuspit regurgitation there may occur venous congestion in the graft (Jullien et al, 1995). On the other hand, spontaneous breathing has been shown to reduce intrapleural pressures, improving venous return and hepatic blood flow; leading to a better recovery (Kaisers et al, 1995). Fast-tracking combined with the restrictive fluid management have been shown to result in rapid recovery (Rossaint

Fast-tracking of the patients with liver transplantation is usually safe and well tolerated; postoperative mechanical ventilation is no longer required for the majority of patients who are devoid of risk factors (Glanemann, 2007). However, as the Model for end-stage liver disease (MELD)-score based organ allocation system has been introduced, the number of patients to be the candidates for fast-tracking is decreased; because it has been shown that early extubation also has its own complications including postoperative ventilatory failure resulting in impaired oxygen delivery to the new graft and reintubation for early surgical complications such as bleeding, bile leak, thrombosis or retransplantation (Mandell et al,

**Risk factors** for prolonged mechanical ventilation after liver transplantation has been described in a statistical analysis. Acccording to this analysis, encephalopathy and a body mass index >34 were significantly associated with failure, thus cannot be extubated in the operating room. Primary graft dysfunction, renal failure, cardiovascular failure, neurological

generally a reduction in the postoperative ventilation time (Glanemann, 2007).

Guevara, 2008).

et al, 1990).

2007).

**3.6 Early-extubation (fast-tracking)** 

impairment, use of >12 units of red blood cells and pulmonary edema cannot tolerate extubation within 3 hours postoperatively. Acute liver failure, retransplantation, severe preservation injury to the graft, mechanical ventilation prior to surgery and use of >15 units of red blood cells and fresh frozen plasma require mechanical ventilation at least 24 hours postoperatively (Mandell, 2002).
