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Goldstein MA, Karlik J, Kamat PP, Lo DJ, Liu K, Gilbertson LE. Utilization of immediate extubation in a multidisciplinary pathway for pediatric liver transplantation associated with improved postoperative outcomes. Pediatr Transplant 2024; 28:e14722. [PMID: 38553820 DOI: 10.1111/petr.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/29/2024] [Accepted: 02/08/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Immediate extubation is becoming more common in liver transplantation. However, limited data exist on how to identify pediatric patients with potential for successful immediate extubation and how this intervention may affect recovery. METHODS This retrospective review evaluated patients who underwent liver transplantation from 2015 to 2021 at Children's Healthcare of Atlanta. Preoperative status and intraoperative management were evaluated and compared. Outcomes comprised thrombosis, surgical reexploration, retransplantation, as well as reintubation, high flow nasal cannula (HFNC) usage, postoperative infection, the length of stay (LOS), and mortality. RESULTS A total of 173 patients were analyzed, with 121 patients (69.9%) extubated immediately. The extubation group had older age (median 4.0 vs 1.25 years, p = .048), lower PELD/MELD (28 vs. 34, p = .03), decreased transfusion (10.2 vs. 41.7 mL/kg, p < .001), shorter surgical time (332 vs. 392 min, p < .001), and primary abdominal closure (81% vs. 40.4%, p < .001). Immediate extubation was associated with decreased HFNC (0.21 vs. 0.71 days, p = .02), postoperative infection (9.9% vs. 26.9%, p = .007), mortality (0% vs. 5.8%, p = .036), and pediatric intensive care unit LOS (4.7 vs. 11.4 days, p < .001). The complication rate was lower in the extubation group (24.8% vs. 36.5%), but not statistically significant. CONCLUSIONS Approximately 70% of patients were able to be successfully extubated immediately, with only 2.5% requiring reintubation. Those immediately extubated had decreased need for HFNC, lower infection rates, shorter LOS, and decreased mortality. Our results show that with proper patient selection and a multidisciplinary approach, immediate extubation allows for improved recovery without increased respiratory complications after pediatric liver transplantation.
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Affiliation(s)
- Matthew A Goldstein
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joelle Karlik
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pradip P Kamat
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Denise J Lo
- Department of Surgery, Emory Transplant Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Katie Liu
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laura E Gilbertson
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
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Ejtehadi F, Firoozifar M, Shakeri J, Jafari P, Sivandzadeh GR, Motazedian N, Shamsaeefar A, Niknam R, Shahramian I, Tahani M. Predictive Score for Early Successful Tracheal Extubation After Liver Transplant: A Case-Control Study. EXP CLIN TRANSPLANT 2023; 21:735-742. [PMID: 37885289 DOI: 10.6002/ect.2023.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
OBJECTIVES Prolonged tracheal intubation and mechanical ventilation after liver transplant increase postoperative complications. Hence, timely extubation should be considered; however, a standard clinical criteria set or scoring system to select patients has not been established for early extubation after livertransplant.We investigated the factors that affect early extubation to design a predictive scoring system for early extubation. MATERIALS AND METHODS This study is a case-control study of adult liver transplant patients. Preoperative, intraoperative, and postoperative clinical data were collected. Early extubation was defined as tracheal extubation immediately or up to 6 hours posttransplant. The variables were compared between the early extubation group and the delayed extubation (>6 hours) group. RESULTS Our study enrolled 237 patients; among them, 57 patients (24%) were in the early extubation group, and 180 (76%) were in the delayed extubation group. Multiple logistic regression analysis showed that postoperative base excess level at admission to the intensive care unit, number of units of packed red blood cells transfused during surgery, urine volume, and excess base level 6 hours after surgery were the main predictors of successful early extubation. CONCLUSIONS The initial base excess level at the entrance to the intensive care unit(postsurgery) and 6 hours after surgery, packed red blood cell volume transfused during surgery, and urine volume 6 hours after surgery are the main predictors for a successful early tracheal extubation.These factors are considered for the Shiraz Extubation Predictor formula.
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Affiliation(s)
- Fardad Ejtehadi
- From the Gastroenterohepatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Sahinturk H, Ozdemirkan A, Zeyneloglu P, Torgay A, Pirat A, Haberal M. Risk Factors for Postoperative Prolonged Mechanical Ventilation After Pediatric Liver Transplantation. EXP CLIN TRANSPLANT 2021; 19:943-947. [DOI: 10.6002/ect.2018.0317] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Partain KN, Mpody C, Rodgers B, Kenney B, Tobias JD, Nafiu OO. Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. J Pediatr Surg 2021; 56:1114-1119. [PMID: 33745739 DOI: 10.1016/j.jpedsurg.2021.02.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children. METHOD We identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV. RESULTS We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75-13.75). CONCLUSION Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.
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Affiliation(s)
- Kristin N Partain
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christian Mpody
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brandon Rodgers
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Kenney
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Olubukola O Nafiu
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA.
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Knaup E, Nosaka N, Yorifuji T, Tsukahara K, Naito H, Tsukahara H, Nakao A. Long-stay pediatric patients in Japanese intensive care units: their significant presence and a newly developed, simple predictive score. J Intensive Care 2019; 7:38. [PMID: 31384469 PMCID: PMC6664501 DOI: 10.1186/s40560-019-0392-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/16/2019] [Indexed: 12/15/2022] Open
Abstract
Background The length of stay (LOS) in intensive care units (ICUs) has been used as a good indicator not only for resource consumption but also for health outcomes of patients. However, data regarding pediatric LOS in Japanese ICUs are limited. The primary aim of this study was to characterize the Japanese pediatric ICU patients based on their LOS. Second, we aimed to develop a simple scoring system to predict long-stay pediatric ICU patients on admission. Methods We performed a retrospective cohort study using consecutive pediatric data (aged < 16 years) registered in the Japanese Registry of Pediatric Acute Care (JaRPAC) from October 2013 to September 2016, which consisted of descriptive and diagnostic information. The factors for long-stay patients (LSPs; LOS > 14 days) were identified using multiple regression analysis, and subsequently, a simple predictive scoring system was developed based on the results. The validity of the score was prospectively tested using data from the JaRPAC registration from October 2016 to September 2017. Results Overall, 4107 patients were included. Although LSPs were few (8.0% [n = 330]), they consumed 38.0% of ICU bed days (9750 for LSPs versus 25,659 overall). Mortality was seven times higher in LSPs than in short-stay patients (9.1% versus 1.3%). An 11-variable simple predictive scoring system was constructed, including Pediatric Index of Mortality 2 ≥ 1 (2 points), liver dysfunction (non-post operation) (2 points), post-cardiopulmonary resuscitation (1 point), circulatory disorder (1 point), post-operative management of liver transplantation (1 point), encephalitis/encephalopathy (1 point), myocarditis/cardiomyopathy (1 point), congenital heart disease (non-post operation) (1 point), lung tissue disease (1 point), Pediatric Cerebral Performance Category scores ≥ 2 (1 point), and age < 2 years (1 point). A score of ≥ 3 points yielded an area under the receiver operating characteristic curve (AUC) of 0.79, sensitivity of 87.0%, and specificity of 59.4% in the original dataset. Reproducibility was confirmed with the internal validation dataset (AUC 0.80, sensitivity 92.6%, and specificity 60.2%). Conclusions Pediatric LSPs possess a significant presence in Japanese ICUs with high rates of bed utilization and mortality. The newly developed predictive scoring system may identify pediatric LSPs on admission. Electronic supplementary material The online version of this article (10.1186/s40560-019-0392-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emily Knaup
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Nobuyuki Nosaka
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,3Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Takashi Yorifuji
- 4Department of Human Ecology, Graduate School of Environmental and Life Science, Okayama University, Okayama, Japan
| | - Kohei Tsukahara
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hiromichi Naito
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Hirokazu Tsukahara
- 2Department of Pediatrics, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Atsunori Nakao
- 1Department of Emergency, Critical Care and Disaster Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
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Sahinturk H, Ozdemirkan A, Yilmaz O, Zeyneloglu P, Torgay A, Pirat A, Haberal M. Immediate Tracheal Extubation After Pediatric Liver Transplantation. EXP CLIN TRANSPLANT 2018; 19:1063-1068. [PMID: 30346263 DOI: 10.6002/ect.2018.0067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We examined whether immediate tracheal extubation among pediatric liver transplant recipients was safe and feasible. MATERIALS AND METHODS We retrospectively analyzed medical records of pediatric liver transplant recipients at Baskent University Hospital from January 2012 to December 2017. We grouped children who were extubated in the operating room versus those extubated in the intensive care unit. RESULTS In our study group of 81 pediatric patients, median age was 4 years (range, 4 mo to 16 y) and 44 (54%) were male. Immediate tracheal extubation in the operating room was performed in 39 patients (48%). Children who remained intubated (n = 42) had more frequent massive hemorrhage (14% vs 0%; P = .015), received larger amounts of packed red blood cells (19.3 vs 10.2 mL/kg; P < .001), and had higher serum lactate levels (9.0 vs 6.9 mmol/L; P = .001) intraoperatively. All children with open abdomens postoperatively remained intubated (n = 7). Patients extubated in the operating room received less vasopressors (1 [3%] vs 12 [29%]; P = .002) and antibiotics (11 [28%] vs 22 [52%]; P = 0.041) and developed infections less frequently postoperatively (3.0 [8%] vs 15.0 [36%]; P = .003). Children extubated in the operating room had shorter mean stay in the intensive care unit (2.0 vs 4.5 days; P < .001). Hospital mortality was higher in children who remained intubated (12% vs 0%; P = .026). CONCLUSIONS Immediate tracheal extubation was well tolerated in almost half of our patients and did not compromise their outcomes. Patients who remained intubated had longer intensive care unit stays and higher hospital mortalities. Therefore, we recommend immediate tracheal extubation in the operating room after pediatric liver transplant among those children without intraoperative requirements for massive blood transfusion, high-dose vasopressors, high serum lactate levels, and open abdomen.
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Affiliation(s)
- Helin Sahinturk
- >From the Anesthesiology and ICM Department, Baskent University Faculty of Medicine, Ankara, Turkey
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