Comprehensive quality initiative leads to immediate postoperative extubation following liver transplant |
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| Affiliation: | 1. Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA;2. The Johns Hopkins University School of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA;3. Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD, USA;4. Department of Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD, USA;1. University of Iowa, Carver College of Medicine, Department of Anesthesia, Division of Management Consulting, 200 Hawkins Drive, Iowa City, IA 52242, United States of America;2. University of Miami, Miller School of Medicine, Department of Anesthesiology, Perioperative Medicine and Pain Management, 1611 NW 12th Avenue (C-301), Miami, FL 33136, United States of America;1. Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA;2. Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, TMP 3, New Haven, CT 06510, USA;1. Medical School of Nantong University, Nantong, Jiangsu, PR China;2. School of Public Health, Nantong University, Nantong, Jiangsu, PR China;1. Department of Anaesthesiology, UZ Leuven, Department of Cardiovascular Sciences, Group Biomedical Sciences, KU Leuven, Leuven, Belgium;2. Department of Obstetrics and Gynaecology, UZ Leuven, Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Leuven, Belgium;3. Centre for Surgical Technologies, Faculty of Medicine, KU Leuven, Leuven, Belgium;4. Department of Paediatric Surgery, Texas Children''s Hospital, Houston, TX, United States of America;5. Department of Obstetrics and Gynaecology, UZA, Antwerp, Belgium;6. Department of Obstetrics and Gynaecology, University Hospitals Tanta, Egypt;7. Institute for Women''s Health, University College London, London, United Kingdom;1. Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Inova Fairfax Hospital/Inova Heart and Vascular Institute, 3300 Gallows Road, Falls Church, VA 22042, USA;2. Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Emory University, 1364 Clifton Rd. Suite C220, Atlanta, GA 30322, USA |
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| Abstract: | BackgroundImmediate postoperative extubation (IPE) can reduce perioperative complications and length of stay (LOS), however it is performed variably after liver transplant across institutions and has historically excluded high-risk recipients from consideration. In late 2012, we planned and implemented a single academic institution structured quality improvement (QI) initiative to standardize perioperative care of liver transplant recipients without exceptions. We hypothesized that such an approach would lead to a sustained increase in IPE after primary (PAC) and delayed abdominal closure (DAC).MethodsWe retrospectively studied 591 patients from 2013 to 2018 who underwent liver transplant after initiative implementation. We evaluated trends in incidence of IPE versus delayed extubation (DE), and reintubation, LOS, and mortality.ResultsOverall, 476/591 (80.5%) recipients underwent PAC (278 IPE, 198 DE) and 115/591 (19.5%) experienced DAC (39 IPE, 76 DE). When comparing data from 2013 to data from 2018, the incidence of IPE increased from 9/67 (13.4%) to 78/90 (86.7%) after PAC and from 1/12 (8.3%) to 16/23 (69.6%) after DAC. For the same years, the incidence of IPE after PAC for recipients with MELD scores ≥30 increased from 0/19 (0%) to 12/17 (70.6%), for recipients who underwent simultaneous liver-kidney transplant increased from 1/8 (12.5%) to 4/5 (80.0%), and for recipients who received massive transfusion (>10 units of packed red blood cells) increased from 0/17 (0%) to 10/13 (76.9%). Reintubation for respiratory considerations <48 h after IPE occurred in 3/278 (1.1%) after PAC and 1/39 (2.6%) after DAC. IPE was associated with decreased intensive care unit (HR of discharge: 1.92; 95% CI: 1.58, 2.33; P < 0.001) and hospital LOS (HR of discharge: 1.45; 95% CI: 1.20, 1.76; P < 0.001) but demonstrated no association with mortality.ConclusionA structured QI initiative led to sustained high rates of IPE and reduced LOS in all liver transplant recipients, including those classified as high risk. |
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