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Acute hepatic failure (ALF) is an uncommon disease characterized by a rapid deterioration of the hepatic function with severe derangements of the mental status in previously healthy subjects due to massive hepatocytes necrosis. Neurological impairment, due to intracranial hypertension and cerebral ischemia, is a key factor because it is a main criterion to decide when to proceed to liver transplantation, which is only treatment for these patients. Therefore, neurological monitoring holds an essential role in the clinical management of ALF patients but it needs to be performed at the point-of-care in the majority of the cases as such critically ill patients cannot be moved away from the ICU because they frequently need continuous hemodynamic, ventilatory and renal support. We herein report and discuss our experience relating to the use of transcranial sonography as a neuro-monitoring tool in ALF patients. In our series this technique allowed a repeatable and reliable non-invasive assessment of cerebral blood flow changes at the bedside thus avoiding the complications associated with the use of an intracranial probe to measure intra-cranial pressure and making it possible to correctly evaluate the timing and feasibility of liver transplantation. [ABSTRACT FROM AUTHOR]

Background and Objective: Cholangiocarcinoma (CCA) is the second commonest primary liver malignancy. Nowadays, the only available treatment with curative intent of intrahepatic cholangiocarcinoma (iCCA) is surgical resection, with a 5-year overall survival (OS) of 25-40%. However, recurrence rate remains high. In this comprehensive review, we describe the newest surgical strategies for iCCA management, including vascular resection, the role of mini-invasive surgery, liver transplant, strategies for future liver remnant augmentation, and the role of neoadjuvant therapies., Methods: A review of medical databases (PubMed, Scopus and Cochrane Database) was conducted selecting most relevant articles in English language without a specific timeframe., Key Content and Findings: Multifocal presentation, vascular, perineural invasion, and lymph nodes involvement are associated with poor outcome. Prognostic factors are being investigated to improve therapeutic approach and outcomes. The role of lymph nodes dissection remains debated. Harvesting at least 6 lymph nodes is recommended to ensure accurate nodal staging. Liver transplantation (LT) recently represented a treatment option only in patients with unresectable early disease (≤2 cm)., Conclusions: Surgical resection remains the only potentially curative treatment for patients with CCA, but continue understanding in diagnosis, operative technique and chemotherapies are changing the landscape in the prognosis. Multicentric and randomized studies are necessaries in the future research with the intent to personalize the treatments, improve patient selection for the resection and reduce recurrence rate.

Background: As previous studies demonstrated conflicting results, we investigated the hemodynamic and renal outcomes of the intra-operative use of a veno-venous bypass during liver transplantation., Methods: The intraoperative levels of mean artery pressure, cardiac index, inferior vena cava and renal perfusion pressures were compared in liver transplant patients receiving or not the bypass., Results: We enrolled 38 patients: 20 with the bypass and 18 without. No differences characterized the two groups regarding gender (P=0.95), age (P=0.32), BMI (P=0.09), liver disease indicating LT and preoperative serum creatinine levels. Patients with the bypass received more intraoperative fluids (crystalloids and colloids) but with no difference in terms of intraoperative blood products and vasopressors requirements (P=0.33). After clamping of the inferior vena cava, patients with the bypass showed higher mean artery pressure. Simultaneously, pressure in the inferior vena cava below the clamp level sharply increased vs. baseline (P<0.0001) independently of the use of the bypass and remained high until clamp release. Consequently, renal perfusion pressure dropped abruptly (P<0.0001) after vena cava clamping and returned to baseline only upon clamp removal. Overall, 18 subjects developed postoperative acute kidney injury which was equally distributed between patients with (n=9) or without (N.=8) the bypass., Conclusions: Our data suggest that the use of a veno-venous bypass fails to release the increased renal venous backflow from inferior vena cava clamping resulting in renal congestion with reduced renal perfusion pressure.

Ex situ normothermic machine perfusion (NMP) might minimize ischemia/reperfusion injury (IRI) of liver grafts. In this study, 20 primary liver transplantation recipients of older grafts (≥70 years) were randomized 1:1 to NMP or cold storage (CS) groups. The primary study endpoint was to evaluate graft and patient survival at 6 months posttransplantation. The secondary endpoint was to evaluate liver and bile duct biopsies; IRI by means of peak transaminases within 7 days after surgery; and incidence of biliary complications at month 6. Liver and bile duct biopsies were collected at bench surgery, end of ex situ NMP, and end of transplant surgery. Interleukin (IL) 6, IL10, and tumor necrosis factor α (TNF-α) perfusate concentrations were tested during NMP. All grafts were successfully transplanted. Median (interquartile range) posttransplant aspartate aminotransferase peak was 709 (371-1575) IU/L for NMP and 574 (377-1162) IU/L for CS (P = 0.597). There was 1 hepatic artery thrombosis in the NMP group and 1 death in the CS group. In NMP, we observed high TNF-α perfusate levels, and these were inversely correlated with lactate (P < 0.001). Electron microscopy showed decreased mitochondrial volume density and steatosis and an increased volume density of autophagic vacuoles at the end of transplantation in NMP versus CS patients (P < 0.001). Use of NMP with older liver grafts is associated with histological evidence of reduced IRI, although the clinical benefit remains to be demonstrated., (Copyright © 2018 by the American Association for the Study of Liver Diseases.)

Immunosuppressive therapy greatly contributed to making liver transplantation the standard treatment for end-stage liver diseases. However, it remains difficult to predict and measure the efficacy of pharmacological immunosuppression. Therefore, we used a panel of standardized, commonly available, biomarkers with the aim to describe their changes in the first 3 weeks after the transplant procedure and assess if they may help therapeutic drug monitoring in better tailoring the dose of the immunosuppressive drugs. We prospectively studied 72 consecutive patients from the day of liver transplant (post-operative day #0) until the post-operative day #21. Leukocytes, neutrophils, lymphocytes (CD4+, CD8+), natural killer cells, monocytes, immunoglobulins and tacrolimus serum levels were measured on peripheral blood (at day 0, 3, 7, 14, 21 after surgery). Patients who developed infections showed significantly higher CD64+ monocytes on post operative day #7. IgG levels were lower on post operative day #3 among patients who later developed infections. We also found that a sharp decrease in IgA from post operative day #0 to 3 (-226 mg/dL in the ROC curve analysis) strongly correlates with the onset of infections among HCV- patients. No specific markers of rejection emerged from the tested panel of markers. Our results show that some early changes in peripheral blood white cells and immunoglobulins may predict the onset of infections and may be useful in modulating the immunosuppressive therapy. However, a panel of commonly available, standardized biomarkers do not support in improving therapeutic drug monitoring ability to individualize immunosuppressive drugs dosing., (Copyright © 2018. Published by Elsevier B.V.)

Background: Only a few studies have compared solvent/detergent plasma (SD-plasma) to standard fresh-frozen plasma (FFP) in terms of efficacy and safety., Materials and Methods: A systematic review was performed in order to develop a consensus document on the use of SD-plasma. Moreover, a pharmacoeconomic study was performed in order to assess whether the use of SD-plasma can be cost-effective with respect to the use of FFP. A multidisciplinary panel used the systematic review and the GRADE methodology to develop evidence-based recommendations on this topic., Results: Based on moderate to very low quality evidence, the panel developed the following consensus statements: (i) the panel suggested that SD-plasma is safer than FFP; (ii) the panel could not express for or against a greater efficacy of SD-plasma as compared to FFP; (iii) the panel suggested that in patients undergoing liver transplantation SD-plasma can be preferred over FFP; (iv) the panel suggested that SD-plasma can be preferred over FFP in patients with thrombotic thrombocytopenic purpura undergoing plasma-exchange procedures; (v) the panel could not recommend for or against preferring SD-plasma over FFP in critical care patients; and (vi) the panel suggested that the use of SD-plasma can be cost-effective with respect to the use of FFP., Discussion: Data from additional randomised studies are needed to establish more definitive guidelines on the use of SD-plasma.

Purpose: Acute kidney injury remains a serious complication after orthotopic liver transplantation. To date, several 'renal-protective' agents have been explored in this setting but with conflicting and disappointing results. Therefore, our aim is to evaluate the effects of fenoldopam in liver transplant patients with an established renal injury., Methods: In this prospective study, intravenous fenoldopam 0.1 µg/kg/min was administered to consecutive liver transplant patients with postoperative (within 7 days from surgery) stage 2 acute kidney injury (AKI) according to the Acute Kidney Injury Network classification. Actual glomerular filtration rate (GFR; calculated by the iohexol plasma clearance), serum creatinine (SCr) and cystatin C (SCyC) were used to assess the effect of the medication on the patients., Results: During the study, 295 patients underwent liver transplant. Fifty-one patients (17.6%) met the inclusion criteria and the data from 48 patients were analysed. SCr and SCyC levels decreased (p < 0.001 after 48 h; p < 0.0001 after 72 h) and GFR increased (p < 0.001 after 24 h; p < 0.0001 after 72 h). When compared to a cohort of comparable patients with AKI from our historical series, the patients in the present study showed better SCr and SCyC levels. It was not necessary to discontinue the infusion of fenoldopam in any patient because of the occurrence of adverse events potentially attributable to it., Conclusion: We showed that fenoldopam was capable of improving some renal function parameters in postoperative liver transplantation patients with on-going AKI. This preliminary study now sets the stage for a multicenter, randomized, placebo-controlled trial in order to provide definite evidence.

Background: Although orthotopic liver transplantation (OLT) is nowadays considered standard practice at experienced centres, it can still be affected by a significant risk of massive bleeding and its related complications. Solvent/detergent plasma (S/D Plasma) has been proposed as an alternative to fresh frozen plasma (FFP) to curtail such complications. This study aimed at evaluating the efficacy of S/D Plasma in OLT patients by comparing it to FFP., Materials and Methods: Sixty-three OLT patients were randomized into two groups depending on whether they were transfused with FFP or S/D plasma. A thromboelastography-based protocol aimed at achieving and maintaining predetermined coagulation goals was used to guide plasma transfusions. At the beginning and the end of surgery, standard laboratory coagulation tests were performed together with the assessment of the VII, VIII, V, XII factors and S protein blood levels., Results: The two study groups equally achieved the thromboelastography goals but with a reduced amount of transfusions in the S/D plasma group (P < 0.0001). At the end of surgery, factors V and XII and S protein blood levels were lower in the S/D plasma patients who also showed lower INR, aPTT and antithrombin III levels., Conclusion: In cirrhotic patients undergoing OLT, the use of S\D plasma associated with thromboelastography allows the same clinical results but with a significant reduction in the amount of plasma transfusions., (© 2013 International Society of Blood Transfusion.)

Thrombotic thrombocytopenic purpura (TTP) is associated with high mortality rates. TTP may have various and different presentations depending on the organs involved. It is now recognized to be the consequence of reduction of blood levels of the disintegrin and metalloprotease with thrombospondin motifs (ADAMTS)-13. Prompt diagnosis of TTP is paramount, because plasma exchange is the only treatment capable of improving patient's survival with a dual mechanism: removal of anti-ADAMTS-13 auto-antibodies and infusion of the active protease available in the fresh frozen plasma. We report herein on the challenges in diagnosing TTP-like complications of post-surgical facial surgery in a young male patient., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: With this survey, we aimed at investigating the knowledge, recognition and management of intra-abdominal pressure (IAP) and abdominal hypertension (IAH) in Italian Intensive Care Units., Methods: A questionnaire was sent to the ''Intensive Care Unit lead physician'' of 114 italian hospitals., Results: One hundred fourteen questionnaires were sent, and 77 (67.5%) of them were returned completed. IAP was measured in 51 Units (66.3%). The most frequent reasons for not measuring IAP were the lack of a specific IAP monitoring kit (34.6%) and not knowing how to make the measurement (23.0%). Urinary bladder pressure was the only method used to measure IAP, the most frequent timing for IAP measurements was once every 4 h. An IAP value of 15 mmHg was considered to be the threshold for IAH in 33.4% of the cases, whereas in 31.4% of cases it was 20 mmHg. The presence of risk factors for IAH (64.7%) and a previous urgent surgery (21.5 %) were indicators of IAP monitoring. Diagnosis of IAH prompted a surgical consultation and evaluation, also in view of a possible abdominal decompression in 64.7 % of cases. More than half (54.9%, n=28) of the 51 ICUs where IAP was measured reported to be unaware of the World Society of the Abdominal Compartment Syndrome., Conclusion: Italian intensive care unit physicians show a certain interest towards IAP monitoring and its implications in the management of critically ill patients. However, IAP, IAH and abdominal compartment syndrome still require greater basic understanding.

A case of bla(VIM-1) producing E. cloacae disseminated infection in a patient submitted to orthotopic liver transplantation is described. Synergism between colistin, rifampin and imipenem was studied in vitro and this combination of three drugs was used to treat E. cloacae infection. The synergistic activity of this combination was demonstrated showing an increased activity of the serum bactericidal activity in comparison with the bactericidal activity of the serum taken during the previous therapy.

A 16 year-old girl underwent a multifocal (lungs, skin, soft tissues) infection due to multiresistant Acinetobacter baumannii after a car crash. To treat such a severe disease we used a combination therapy of colistin (2 millions Units twice/day), rifampicin (600 mg/day), meropenem (1 g 3 times a day) after a synergistic activity test was performed (checkerboard method on Mueller-Hinton broth and 5x10(5) cfu/mL inoculum). After 24 days, when a significant clinical improvement was gained, the 3-drugs combination therapy was replaced with i.v. levofloxacin 500 mg twice/day but, after 10 days of quinolones therapy, fever started again and the same multidrug resistant (MDR) A. baumannii was isolated from the skin grafts, central venous catheter tip and bronchial alveolar lavage. A combination therapy with colistin and meropenem was therefore started and definitive defervescence was obtained after 10 days. This therapy was continued for 70 days even if the patient was apyretic because A. baumannii was still present in the skin secretions. After 109 days of hospitalization in our intensive care unit, the patient was transferred to a rehabilitative unit. This case shows how useful is, in selected cases, rediscovering old antibiotic drugs, specially when they are adopted as a combination therapy, and highlights the importance of the clinical microbiological laboratory as it may help clinicians in choosing the best drugs combination.

A case of post-transplant malaria is described. The patient presented fever and severe anemia after orthotopic liver transplantation. Diagnosis was made only after the review of donor characteristics. Although a high parasitemia was found at the moment of diagnosis, the treatment with quinine and doxycycline was successful. Donor epidemiology should always be considered for a prompt diagnosis of rare tropical diseases in the graft recipients., (Copyright 2006 AASLD)

This study aims to evaluate and compare the early outcome of both pancreas-alone transplantation (PTA) and simultaneous kidney-pancreas transplantation (SPKT) focusing on the complications affecting the first month after the procedures. The records of all patients who underwent PTA or SPKT were reviewed. We considered the length of ICU stay, the need for postoperative ventilatory support, hemodynamic and metabolic data (arterial pH, serum glucose, need for exogenous insulin), infectious diseases incidence, microbiological colonization rate and any kind of postoperative complication arising during the first month after the transplantation. PTA recipients underwent a quicker surgery (P < 0.01) with shorter ICU stay (P < 0.05) and a lower need for postoperative mechanical ventilation (P < 0.05). They also had a higher hemodynamic stability (P < 0.05) with less cardiological complications (P < 0.05) in the intra- and postoperative phases; bacterial colonisation was also less frequent in PTA recipients (P < 0.05). On the contrary, no significant difference was noted with regard to postoperative nausea/vomiting, sudden myocardial death, ICU re-admissions, graft function, rate of rejection, grafts explantation and re-transplantation. PTA could be considered as preemptive for severe diabetic complications in patients with long-lasting severe type I diabetes. However, establishing the correct timing of PTA is of paramount importance in order not to expose the patients early to risks arising from a major surgery and heavy immunosuppressive treatments.

Background and Objective: Reducing postoperative mechanical ventilation in patients undergoing liver transplantation may have clinical and organizational advantages. On the basis of our experience, we here evaluate the possibility of practising immediate tracheal extubation in the operating theatre., Methods: In this prospective study, patients consecutively undergoing liver transplantation between 1 June 1999 and 31 May 2004 were extubated in the operating theatre at the end of surgery on the basis of standardized and universally accepted criteria, under conditions of haemodynamic and metabolic stability., Results: Two hundred and seven of the 354 patients (58.5%) were extubated immediately after the completion of the surgical procedure (mean time between end of surgery and extubation: 0.4 +/- 1.4 min); two were re-intubated. In the last of the 5 yr of the study, the percentage of immediate extubations increased to 82.5%. During the study period, there was a progressive increase in the number of immediate extubations per individual member of the team of anaesthetists. The pre-transplant Child-Pugh severity of the underlying liver disease did not predict rapid extubation, but the Model for End-stage Liver Disease score of < 11 did (receiver operator characteristic area under the curve = 0.61; P < 0.05)., Conclusions: Immediate extubation after liver transplantation is possible in a substantial percentage of cases; confidence, habit and a spirit of emulation are decisive factors in encouraging anaesthetists to extend this practice to the largest possible number of patients. A successful immediate extubation may be an important indicator of perioperative quality of care in liver transplantation.

The aim of this study was to compare a number of potentially stress-generating factors related to an intensive care unit (ICU) stay from the points of view of patients undergoing liver transplantation or elective major abdominal surgery and their caregivers in order to identify differences and similarities that may help to optimize patient care. The ICU Environmental Stressor Scale questionnaire was administered to 104 liver transplant recipients, 103 major abdominal surgery patients, 35 nurses and 21 physicians. The ICU staff were asked to complete the questionnaire on the basis of their perception of patient stressors. Both patient groups identified Being unable to sleep, Being in pain, Having tubes in nose/mouth, Missing husband/wife, and Seeing family and friends only a few minutes a day as the major stressors; the healthcare providers correctly identified the most stressing factors for the patients, but gave them higher scores. The mean scores were 71.9 +/- 18.7 for the transplant recipients, 66.3 +/- 20.9 for the patients undergoing elective major abdominal surgery, 99.7 +/- 19.2 for the nurses, and 92.7 +/- 16.1 for the physicians (P < 0.001). The qualitative evaluations of potentially stress-inducing ICU situations were substantially the same in the 2 patient groups, but the transplant recipients seemed to feel them more acutely. Although the caregivers identified the most discomforting situations, they overestimated the degree of stress they cause. The staff of each ICU should therefore seek to understand and reduce (even by means of simple interventions) the particular causes of psychophysical stress felt by their patients.

Aim: The aim of this study is to describe personal experience in the intensive management of patients with severe diabetes undergoing pancreas transplantation., Methods: Clinical records of subjects consecutively undergoing an isolated or combined pancreas transplant have been examinated., Results: During the considered period, 10 patients received an isolated pancreas transplant and 43 a simultaneous kidney-pancreas transplantation (SPKT), including 6 using a kidney from a living donor. The mean stay in the Intensive Care Unit (ICU) was 4.7 days: 52 patients (98.2%) were transferred to the Surgical Department, whereas one (1.8%) belonging to the SPKT group died with a non-functioning graft. Ten patients (18.6%) were re-admitted because of the onset of late complications, including one SPKT who died of sudden cardiac death with functioning grafts. Arterial hypertension appeared in 51% of the recipients, and 5.6% experienced at least one hypotensive episode. Cardiac rhythm alterations were diagnosed in 5 subjects (9.4%), and myocardial ischemia in 9 (17%)., Conclusions: Pancreas transplantation is a therapeutic option that can improve patients' quality of life by also slowing down the evolution of diabetes; however, it is important to bear in mind the associated risks. The best results are obtained in patients in whom the disease has not already seriously impaired the function of the various target organs.

Background: The incidence and clinical relevance of increased intraabdominal pressure after orthotopic liver transplantation (OLT) has not yet been evaluated despite the finding that occurrence of this condition in postsurgical critically ill patients may impair various organ functions. The aim of this study was to assess whether the occurrence of abdominal hypertension among a population of OLT recipients was an important cofactor producing early postoperative complications., Method: This prospective clinical study measured abdominal pressure every 6 hours during the intensive care unit (ICU) stay using the urinary bladder method. A value of >/=25 mm Hg was considered high. Hemodynamic status was simultaneously evaluated and renal function assessed based on the hourly urinary output, and by calculating serum creatinine on postoperative days 2 and 4. Renal failure was defined as a serum creatinine level of >1.5 mg/dL, or an increase in peak of >1 mg/L within 72 hours of surgery. The filtration gradient and patient outcomes were also considered., Results: Intraabdominal hypertension was observed in 32% of cases. The subjects displaying high IAP showed significantly lower artery pressure values (P <.01), but did not differ in terms of central venous pressure or cardiac output. High intraabdominal pressure was more frequently associated with renal failure (P <.01), a lower filtration gradient (P <.001), delayed postsurgical weaning from the ventilation (P <.001), and increased ICU mortality (P <.05). A receiver operator characteristic curve analysis showed that the critical IAP values, namely those with the best sensitivity/specificity, were 23 mm Hg for postoperative ventilatory delayed weaning (P <.05), 24 mm Hg for renal dysfunction (P <.05), and 25 mm Hg for death (P <.01)., Conclusions: Abdominal hypertension occurs frequently after OLT and may be associated with a complicated postoperative course.

Hypothesis: Intra-abdominal hypertension frequently threatens renal function early after orthotopic liver transplantation (OLT)., Design: A prospective study of consecutive patients who underwent OLT., Setting: The intensive care unit of a National Health Service teaching hospital., Patients and Main Outcome Measures: The intra-abdominal pressure (IAP) of 108 consecutive patients who underwent OLT was postoperatively measured 3 times a day for 72 hours using the urinary bladder technique. Intra-abdominal hypertension was defined as an IAP of 25 mm Hg or higher., Results: Thirty-four patients (31%) had a high IAP. Acute renal failure developed in 17 recipients (16%), 11 (65%) of whom had intra-abdominal hypertension (P<.01), with a mean +/- SD IAP of 27.9 +/- 9.9 mm Hg vs 18.6 +/- 5.2 mm Hg in those without acute renal failure (P<.001). The subjects with a high IAP were more frequently administered loop diuretics to maintain adequate diuresis (P<.001) and had a low mean arterial pressure on the day of surgery (P<.01), despite the fact that they were given more intravenous fluids (P<.01) and did not differ in the need for inotropic drugs. Logistic regression analysis showed that intraoperative transfusions of more than 15 U, respiratory failure, and intra-abdominal hypertension (P<.01) were independent risk factors for renal failure. The length of intensive care unit stay was similar in the patients with a normal and a high IAP, but mortality was higher among the latter (P =.02)., Conclusions: Intra-abdominal hypertension is common after OLT and is significantly associated with renal failure, reduced urinary output, and intensive care unit mortality. It is, therefore, worth monitoring IAP in those undergoing OLT.

Objective: No data are available on the incidence and clinical relevance of increased intra-abdominal pressure after orthotopic liver transplantation. This study assessed abdominal hypertension in a population of transplanted patients as this may be an important cofactor in early postoperative complications., Design and Setting: Prospective clinical study in an intensive care unit of a national health system teaching hospital, Patients and Measurements: Abdominal pressure was measured every 6 h using the urinary bladder method and was considered elevated when it was 25 mmHg or higher. Hemodynamic status was evaluated at the same times. Renal function was assessed on the basis of hourly urinary output by calculating serum creatinine on postoperative days 2 and 4 and the filtration gradient; patient outcomes were also considered., Results: Intra-abdominal hypertension was observed in 32% of cases; the subjects with high abdominal pressure had significantly lower mean artery pressure values but did not differ in terms of central venous pressure or cardiac output. High intra-abdominal pressure was more frequently associated with renal failure, a lower filtration gradient, delayed postsurgical weaning from ventilation, and a worse outcome., Conclusions: Abdominal hypertension is frequent after liver transplantation and may be associated with a complicated post-operative course.

The aim of this study was to evaluate the efficacy of two antifungal prophylaxis regimens in liver transplant recipients. One hundred and twenty-nine consecutive recipients were randomized to receive sequential treatment with intravenous liposomal amphotericin B + oral itraconazole, intravenous fluconazole + oral itraconazole, or intravenous and oral placebo. Frequency and incidence of mycotic colonization, local and systemic infection of mycotic origin, causes of death, and possible risk factors for mycotic infection were evaluated. The incidence of mycotic colonization was higher in the placebo group ( P<0.01), but there was no significant difference in the incidence of infection between the three groups. Pre-transplant colonization, severity of liver disease, and graft rejection were all risk factors for the development of fungal infection. The routine use of antifungal prophylaxis for all liver transplant recipients does not seem to be justified.

This study of all patients undergoing orthotopic liver transplantation (OLT) at our center between January 1997 and December 1999 evaluated the feasibility and safety of very early tracheal extubation without previous selection. Anesthetic management was the same in all cases, and tracheal extubation was performed on the basis of standardized criteria routinely adopted in operating rooms throughout the world, i.e., no residual curarization or anesthetic action, ability to swallow efficiently, and stable hemodynamics. One hundred sixty-nine patients underwent 181 OLTs during the study period. Tracheal extubation was performed within 3 hours of surgery in 115 cases, 8 hours in 19 cases, and 8 to 24 hours in 10 cases. In 36 cases, artificial ventilation was required for more than 24 hours or weaning was not possible. One patient died of primary graft nonfunction within 24 hours and was excluded from the analysis. The feasibility of early extubation was influenced by the amount of intraoperative transfused blood; efficacy of kidney, cardiac, and pulmonary function; and presence of encephalopathy (P <.001). No correlation was found with age or pre-OLT severity of hepatic disease, and the postoperative period was not compromised by early weaning. Very early extubation was feasible and safe in a large number of unselected transplant recipients, thus suggesting that the definition of early tracheal extubation should be changed from 8 to 3 hours after surgery.