*Purpose: Patients undergoing liver transplantation (LT) have traditionally remained intubated in the early postoperative period. Recently, early extubation and fast track anesthesia (strategy for rapid recovery from anesthesia) have gained popularity as they facilitate early recovery and decrease complications associated with prolonged mechanical ventilation. The aim of our study was to investigate the predictive factors for successful immediate post-operative extubation and to understand the clinical impact of this practice on the postoperative course.

*Methods: This is a single-center, retrospective study of recipients that underwent LT between January 2014 and May 2017. The study was approved by our institutional review board after which data was obtained by electronic chart review. All LT patients were included except for liver-kidney transplants, living donor transplants, and retransplant patients. Donor and recipient characteristics were balanced by propensity score matching (PSM) between the immediate (within 60 minutes of end surgical time) and late extubation (&gt 60 minutes) groups and postoperative outcomes were analyzed. Primary end points assessed included length of ICU stay, hospital stay, respiratory complications, peritransplant costs and 90-day graft outcomes.

*Results: A total of 313 patients were eligible for this study and they were all shifted to ICU post transplant. Seventy Nine (25.2%) were extubated at end of LT (immediate extubation group), 5 (6.3%) of whom were reintubated within first week. On multivariable analysis, longer cold ischemia time (OR 0.67, p=0.001), higher total intraop red blood cell transfusion (OR 0.83, p=0.001) and moderate encephalopathy (OR 0.13, p=0.04) were associated with reduced chance of immediate extubation. Total of 237 patients (79 in immediate group and 158 in delayed group) were matched in PSM model. Immediate extubation group showed significantly lower rate of pulmonary complication in 3 months (13.9% vs. 31.6%, p=0.004), shorter length of ICU stay (2 vs. 3 days, p=0.02), lower post LT ICU costs ($5528 vs $7649, p=0.009) and lower early allograft dysfunction rate (7.6% vs 20.2%, p=0.01). Overall hospital stay and readmission rates were similar. Ninety day graft survival rates were similar (97.5% vs. 98.1%, P=0.75).

*Conclusions: Immediate extubation after LT may decrease risk of early pulmonary complication and reduce ICU stay and costs. Because reintubation was required in 6.3% of this group, close post-operative monitoring in ICU is important.

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