- There is a need to establish dedicated, sub-specialized ICUs to care for complex patients post-liver transplant to avoid complications. - Early extubation in the operating room or within 1 hour of the ICU can be safe and reduce length of stay if patients are properly selected. - Factors like last intraoperative lactate and blood transfusion levels, coagulation status, and urine output can predict candidates for early extubation.

2. • Is There A Need for post transplant Sub-
specialized Units ?
• Timing for extubation.
• Discharge decision and Lenghth of stay ( LOS)
in ICU.
• Risk factors for readmission.

3. • Big
Operation
Incision
Recovery
Complications
• Sakpal SV, Agarwal SK, Saucedo-Crespo H, Auvenshine C, Santella RN, Donahue S, et al. Transplant Critical Care: Is
There A Need for Sub-specialized Units? — A Perspective. J Crit Care Med. 2018;4(3):83–9.

4. • Establishment of a goal-directed, dedicated,
sub-specialized ICU to cater to the critical
needs of complex consequences in this unique
class of patients.
• Sakpal SV, Agarwal SK, Saucedo-Crespo H, Auvenshine C, Santella RN, Donahue S, et al. Transplant Critical Care: Is There A
Need for Sub-specialized Units? — A Perspective. J Crit Care Med. 2018;4(3):83–9.

5. • Avoidance of ICU admission or fast tracking
without ICU admission can be safe and
feasible but need proper selection and better
definition of patients who will benefit from
this protocol.
• Echeverri J, Goldaracena N, Singh AK, Sapisochin G, Selzner N, Cattral MS, et al. Avoiding ICU Admission by Using a
Fast-Track Protocol Is Safe in Selected Adult-to-Adult Live Donor Liver Transplant Recipients. Transplant Direct.
2017;3(10):e213.

6. Variables detect non ICU admission
• Age
• Gender
• BMI
• MELD score
• Pretransplant LOS
• Operative time
• Blood transfusion
• Vasopressors
• Bulatao IG, Heckman MG, Rawal B, Aniskevich S, Shine TS, Keaveny AP, et al. Avoiding stay in the intensive care
unit after liver transplantation: A score to assign location of care. Am J Transplant. 2014;14(9):2088–96.

8. • Glanemann M, Busch T, Neuhaus P, Kaisers U. Fast tracking in liver transplantation. Immediate postoperative tracheal extubation:
Feasibility and clinical impact. Swiss Med Wkly. 2007;137(13–14):187–91.

9. Early extubation ?
Immediate in OR
In ICU within one hour
Why?
Prolonged MV = deleterious effect , more sedation
drugs and prolonged LOS
Early extubation increased patient and graft
survival, shortened hospital stay, and reduced
treatment costs
Lee S, Sa GJ, Kim SY, Park CS. Intraoperative predictors of early tracheal extubation after living-donor liver transplantation. Korean J
Anesthesiol. 2014;67(2):103–9.

10. Predictors of early extubation

11. • Predictors of early extubation
• Last intraoperative(IO) serum lactate
• IO blood transfusion ( FFP )
• Last coagulation lab
• UOP
• Ascitic fluid removed
Sanghavi D, Sarvottam K, Kashyap R, Pannu B, Heimbach J, Iyer V. Factors Influencing Fast Track Extubation
Following Liver Transplant Surgery: A 3 Year Mayo Clinic Experience. Chest . 2016;149(4):A150.
Elnour S, Milan Z. Factors that may affect early extubation after liver transplantation. 2016;(August 2015):9–15.

12. Exclusion for early extubation
• Acute liver failure and multi-organ failure
• Multi-organ transplantation
• Dialysis dependence, acute renal failure
• Re-transplantation for primary non-
functioning graft
• Pulmonary hypertension (MPAP >35 mmHg)
• Encephalopathy grade 3 or 4
• Bulatao IG, Heckman MG, Rawal B, et al. Avoiding stay in the intensive care unit after liver transplantation: a
score to assign location of care. Am J Transplant 2014 Sep;14(9):2088– 96. 3

14. • Wagener G. Liver anesthesiology and critical care medicine: Second edition. Liver Anesthesiol Crit Care Med Second Ed. 2018;1–542.

16. • Immunosupressive drugs started intially
intraoperative then in day 1
• Decision when and how to start done by
hepatologist, intensivist and transplant
surgeon.
• Ranal and neurological complication of
immunosupression should be excluded before
discharge

17. • Exclusion of coagulopathy should be excluded
before discharge by conventional labs and
ROTEM
• Sihler KC, Napolitano LM. Complications of massive transfusion. Chest. 2010;137(1):209–20.

18. • Wagener G. Liver anesthesiology and critical care medicine: Second edition. Liver Anesthesiol Crit Care Med Second Ed. 2018;1–542.

19. • Does the patient needs ICU intervention?
• Patient requires level of monitoring that non
ICU floor can not provide ?
• The patient requires medication that can not
be administered outside ICU ?

20. • Readmissions after OLT represent a significant health care
burden. Readmission is associated with worse long-term
outcomes and significantly reduced patient and graft survival
• Paterno F, Wilson GC, Wima K, Quillin RC 3rd, Abbott DE, Cuffy MC, et al. Hospital utilization and consequences of readmission after
liver transplantation. Surgery 2014;156: 871-878.

21. Causes
• Infectious
• Medication related
• Biliary complication
• Pulmonary
• Acute cellular rejection
• Anemia
• Mental status change
• Renal failure
• Malnutrition
• Venous thromboembolism
Patel MS, Mohebali J, Shah JA, Markmann JF, Vagefi PA. Readmission following liver transplantation: an
unwanted occurrence but an opportunity to act. Hpb. 2016;18(11):936–42.

22. • Risk factors
• Old age
• Pre-transplant CKD
• Intraoperative RBC transfusion
• New-onset atrial fibrillation during ICU stay
Son YG, Lee H, Oh SY, Jung CW, Ryu HG. Risk Factors for Intensive Care Unit Readmission After Liver Transplantation: A
Retrospective Cohort Study. Ann Transplant. 2018;23:767–74.