08 | Early extubation after liver transplantation: is it always possible? Preliminary data from the Petalo Liver Transplantion database in a referral center in Puglia

Background. Early Extubation (EE) is a fast-track surgery strategy aimed at enhancing recovery after Orthotopic Liver Transplantation (OLT). The aim of this study was to compare EE in the Operating Room (OR) with Delayed Extubation (DE) in the Intensive Care Unit (ICU), in terms of patients’ clinical characteristics and outcomes.

Methods. This retrospective single-center study included adult patients who underwent deceased-donor OLT between April 2024 and December 2024, excluding those with portopulmonary or hepatopulmonary syndrome.

Patients extubated in the OR (EE group) and those extubated in the ICU (DE group) were compared regarding transplant indication, norepinephrine dose and lactate levels at the end of surgery, organ-related complications, and hepatorenal function (AST/ALT, total bilirubin, INR, creatinine) on postoperative day 7, ICU and hospital length of stay, and mortality.

Data were extracted from the multicenter registry PROSAFE, Petalo Trapianti di Fegato (GiViTI),and analyzed using the Kruskal–Wallis test for continuous variables and the chi-square test for categorical variables (α=0.05).

Results. Of the 43 patients who underwent OLT, 37 were enrolled: 59% in the EE group and 41% in the DE group. The two groups were comparable in terms of transplant indication.

At the end of surgery, the DE group showed higher norepinephrine requirements (0.16 vs 0.04 mcg/kg/min; p<0.001) and lactate levels (6.6 vs 3.9 mmol/L; p=0.016). Mechanical ventilation weaning was completed within the first 24 hours in the ICU.

No significant differences were observed in graft dysfunction, hepatorenal function, or ICU complications, although the EE group showed a higher reintubation rate (13.3% vs 0%; p=0.078).

ICU length of stay was longer in the DE group (4.4 vs 2.4 days; p=0.05), whereas hospital length of stay and ICU mortality were similar between groups.

Conclusions. Delayed extubation after OLT is reserved for patients with hemodynamic instability at the end of surgery and does not appear to be associated with early complications. Further studies with larger sample sizes are needed to better define criteria for early extubation and assess its impact on hospital resource utilization.