P018: THE EFFECTIVENESS OF INTRAOPERATIVE ENDOTRACHEAL EXTUBATION IN LIVER TRANSPLANTATION
Ciara M Saccente; Rehan T Shah; Kha D Vo; Jonathan R Hooper; Asad Bashir, MD
University of Florida College of Medicine
Introduction/Background: Early endotracheal extubation practices have been increasingly adopted in recent years, due to their success in enabling earlier recovery without increasing morbidity.1 In liver transplantation, early extubation has been associated with reduced pulmonary complications, decreased costs, and shorter lengths of stay in the intensive care unit.2 Moreover, early extubation is also regarded in improved 1-year and 3-year graft survival rates by reducing the physiological stress associated with mechanical ventilation, prolonged ICU stays, and other post-operative factors.9 This success has been noted in various patients and is gradually being adopted in different hospitals around the world. However, no routine standard exists regarding its respective implementation,3,4 including a clearly defined timing of extubation, standardized MELD thresholds, or specific physiological parameters that reliably support early extubation. Moreover, extubation decisions are further complicated by intraoperative factors, preoperative physiological conditions, and potential injury or complications during surgery.5 Consequently, such nuanced factors predicating extubation decision-making inherently induce variability in its implementation.
Methods: This retrospective cohort study with post hoc analysis will include all liver transplant surgeries performed at the University of Florida Health, Shands Hospital, since the program's inception to date. Our study aims to provide critical insights into the association of intraoperative extubation with MELD scores, the incidence of intraoperative extubation at UF Health Shands with regard to liver transplantation, the correlation of intraoperative extubation and the length of ICU stay, alongside the exploration of intraoperative extubation with graft function and hemodynamic status. For now, a background narrative literature review was conducted to identify studies examining intraoperative extubation following liver transplantation. The search was performed independently by two reviewers. Search terms included combinations of early extubation, liver transplantation, MELD score, postoperative outcomes, ICU length of stay, and pulmonary complications. No meta-analysis was conducted.
Results: Prior studies evaluating early extubation after liver transplantation indicated that patients with a MELD score of >11 were more likely to require longer intubation.6 In a larger retrospective cohort of 1,555 patients, it was revealed that increasing MELD-Na quartiles were associated with increasing rates of delayed extubation.2 More recent literature also emphasizes the nuance necessary in successful early extubation, where extubation outcomes are better predicted using cohesive metrics rather than simply MELD scores. El Moheb et al. (2025) developed a 0-4 point scale integrating both MELD score and transfusion requirements to offer a multivariable model to predict extubation success.8
Discussion/Conclusion: Indeed, we emphasize that a low MELD score alone should not be used as a definitive outcome for extubation readiness, as patients with lower MELD scores still experience complex intraoperative courses that could increase extubation risk. This retrospective study at UF Health Shands aims to clarify the relationship between MELD score, intraoperative extubation practices, and postoperative outcomes, including ICU length of stay, graft function, and hemodynamic stability. By characterizing institutional practice over time, this work seeks to inform the development of more consistent, evidence-based extubation strategies and advance patient safety in liver transplantation.