*Purpose: With the current demand for liver transplantation, sicker patients are frequently transplanted. These patient are at a higher risk of significant morbidity following surgery, including respiratory failure. This study evaluated the phenotype that characterizes liver transplant candidates that may benefit from early tracheostomy.

*Methods: A single center retrospective review of all liver transplant candidates. Patients who eventually required tracheostomies were identified and compared to their counterparts. Ventilatory parameters and patient characteristics were compared.

*Results: Of the 130 liver transplants performed between January 2012 and December 2017, 11 patients required tracheostomy. Although the patients in the tracheostomized population (TP) did not have significantly worse preoperative functional status (< 4 metabolic equivalents; 64% vs 42%, p=0.21), patients who required tracheostomies did have a greater native MELD score (37 vs 30, p<0.05), at the time of transplantation. When comparing intra-operative characteristics, patient who eventually succumbed to respiratory failure had decreased PaO2/FiO2 ratios at the start of surgery and remained significantly lower for the duration of surgery compared to the non-tracheostomy group (p <0.05). TP patients required more net fluid resuscitation intra-operatively (7.3 vs 5.0 liters, p<0.05), increased length of time to attempted extubation (3.5 vs 1 day, p<0.05), longer mechanical ventilation days (15 vs 1 day, p<0.05), increased length of stay (37 vs 9 days, p<0.05) and higher 1-year mortality (36% vs 8%, p<0.05).

*Conclusions: After reviewing the pre-operative and intra-operative data, patients with a high MELD score (>30), net post-operative fluid balance > 5L, and PaO2/FiO2 ratio ≤ 300 who fail to wean off mechanical ventilation after 72 hours may benefit from tracheostomy during the post-operative period.

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