Association of Driving Pressure With Delayed Extubation After Pediatric Liver Transplantation

Mechanical ventilation following pediatric liver transplant remains common and extends weaning duration. The aim of this study was to identify the risk factors for delayed extubation in children following liver transplantation, focusing on respiratory mechanics. We also compared respiratory morbidity and mortality according to the extubation status.

In this retrospective, monocentric cohort study, children under 18 years were included if they underwent primary liver transplant. The primary end point was delayed extubation, defined as any extubation 48 hours after transplantation. Preoperative graft and subject characteristics, as well as intra- and postoperative ventilatory and hemodynamic parameters, were tested to assess their association with delayed extubation in univariate then multivariate analyses, using 2 logistic regression models ("intra-operative model" and "pediatric intensive care unit [PICU] model").

Ninety-six subjects were included, among whom 46 (47%) had delayed extubation. In the operating room, independent risk factors for delayed extubation were the amount of transfusions (odds ratio [OR] 2.77, 95% CI, 1.19-9.04, P = .045) and maximal blood lactatemia (OR 1.62, 95% CI, 1.15-2.53, P = .01). In the PICU, driving pressure (ΔP) 12 hours after the surgery and the presence of a postoperative complication (any graft vessel thrombosis, severe bleeding, and/or surgical revision) were independently associated with delayed extubation (OR 1.31, 95% CI, 1.05-1.70, P = .03 for ΔP, and OR 14.55, 95% CI, 2.83-181.29, P = .004 for any complication). When excluding 28 children with surgical revision, ΔP remained associated with delayed extubation, whereas complications were not.

A higher ΔP in the early hours following pediatric liver transplantation was associated with prolonged mechanical ventilation, along with hyperlactatemia and transfusions during surgery, and postoperative complications.