R. A. Jean1, S. M. Miller1, A. S. Chiu1, P. S. Yoo1 1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA
Introduction: Morbidity and mortality are relatively high following liver transplantation. Furthermore, severe pulmonary complications progressing to respiratory failure, though rare, are associated with increased postoperative mortality and prolonged hospitalization. Although these cases may require tracheostomy, there is uncertainty regarding how soon this should be pursued. The purpose of this study is to quantify the comparative effectiveness of early versus late tracheostomy in postoperative liver transplant patients in relation to in-hospital mortality and length of stay.
Methods: The National Inpatient Sample (NIS) dataset between 2000 and 2014 was queried for discharges among adult patients who underwent both orthotopic liver transplant (OLT) and post-transplant tracheostomy (PTT). Patients receiving tracheostomy by post-transplantation day 14 were classified as “early” tracheostomies, while those receiving after day 14 were classified as “late". In-hospital mortality was compared between groups using adjusted logistic regression models. Cox proportional hazards regression was used to model the impact of early tracheostomy on post-tracheostomy length of stay (PTLOS), accounting for the competing risk of inpatient mortality.
Results: There were 2,149 weighted discharges after OLT and PTT during the study period, of whom 783 (36.4%) were performed by post-transplant day 14 and classified as “early.” Patients receiving early PTT were more likely to have a Charlson Comorbidity score (CCI) of 3+ compared to those receiving late PTT (early 71.1% vs late 60.0%, p=0.04), but there were otherwise no significant baseline differences between groups. Despite this increased comorbidity, early PTT had significantly lower in-hospital mortality (early 26.4% vs late 36.7%, p=0.01). Unadjusted median PTLOS was 31 days (IQR 20-48 days) for early PTT, versus 39 days (IQR 23-61 days) for late PTT (p=0.03). In adjusted logistic regression, early PTT was associated with 37% decreased odds of in-hospital mortality in comparison to late PTT (OR 0.63, p=0.04). Furthermore, after accounting for competing risk of mortality, early tracheostomy had a 41% higher daily rate of discharge alive during the post-transplant hospitalization (HR 1.41, p<0.0001).
Conclusion: Among patients with OLT, early PTT, despite being performed on patients with significantly higher comorbidity scores, was associated with lower in-hospital mortality, lower PTLOS, and quicker discharge alive. These results support our hypothesis that among patients with respiratory failure after OLT, early consideration of PTT may portend more favorable outcomes than a delayed approach.
