Rates, Outcomes and Predictors of Immediate and Early Extubation After Pediatric Liver Transplantation

INTRODUCTION: Pediatric patients undergoing liver transplantation (LT) often require postoperative mechanical ventilation, which can increase the risk of complications such as ventilator-associated pneumonia (VAP) and higher intensive care unit (ICU) resource utilization. Advances in perioperative care have made immediate intraoperative extubation (IE) and early extubation (EE) feasible and safe; however, evidence in pediatric LT remains limited, and standardized extubation criteria are lacking. This study aimed to evaluate the incidence, outcomes, and predictors of successful IE/EE after pediatric LT at a high-volume North American center. METHOD: Perioperative data were retrospectively reviewed for patients aged ≤ 18 years who underwent isolated LT between January 1, 2013, and December 31, 2021. Patients undergoing combined liver-bowel transplantation, retransplantation, or liver autotransplantation were excluded. Recipients were categorized into three groups based on extubation timing: IE, EE (≤ 24 h), and delayed extubation (DE; > 24 h). Multivariable logistic regression was used to identify independent predictors of IE/EE. RESULTS: Of 245 patients, 33 underwent IE and 110 underwent EE, with no cases of reintubation. Over the study period, rates of IE and EE increased steadily. The IE/EE cohort had significantly shorter ICU and hospital lengths of stay compared to the DE group. Multivariable analysis identified age, preoperative care setting, and use of regional anesthesia as significant independent predictors of successful IE/EE. The predictive model demonstrated good discrimination (C-statistic 0.82; 95% CI 0.77-0.88). CONCLUSION: IE/EE after pediatric LT is increasingly common and has been associated with a high degree of safety and favorable outcomes. Recipient age, preoperative care setting, and intraoperative regional anesthesia are significant predictors of success. Over 9 years, growing experience was associated with higher IE/EE rates, reduced ICU stays, and shorter hospital length of stay, supporting earlier recovery and optimized resource utilization.