Off the Vent and on the Mend: Predicting Successful On-Table Extubation Following Liver Transplantation

Historically, patients remain intubated at the conclusion of liver transplantation; however, early extubation improves outcomes and lessens resource utilization. This cohort study aimed to create a model predicting which liver transplant recipients would be likely to extubate early.

All adult first-time liver-only recipients at a single center from January 2022 to March 2025 were included. The primary outcome was on-table extubation (OTE), and secondary outcomes were intensive care unit length of stay and reintubation within 48 h. Multivariable logistic regression was used to devise a score predicting early extubation.

Of 325 patients in the study, 107 (32.9%) were extubated in the operating room. Only 2 (1.9%) were subsequently reintubated within 48 h, excluding those who returned to the operating room. OTE was associated with a nearly 60% decrease in ICU LOS on adjusted models (estimate 0.41, P < 0.01). Model for End-Stage Liver Disease score (0.92, 95% confidence interval [CI]: 0.89-0.95, P < 0.01), prior abdominal surgery (0.58, 95% CI 0.35-0.97, P = 0.04) and elevated donor bilirubin (0.60, 95% CI: 0.34-1.07, P = 0.09) were associated with lower odds of OTE. The use of normothermic machine perfusion increased the odds of OTE (1.85, 95% CI: 1.10-3.10, P = 0.02). A multivariable model with these 4 preoperatively known variables had an area under the curve of 0.74, with 79% sensitivity, 60% specificity, 49% positive predictive value, and 86% negative predictive value in predicting OTE at the optimal cutoff value.

Early extubation following liver transplant is safe and is associated with shorter intensive care unit length of stay. A model of preoperatively known factors can identify patients who are likely to undergo early extubation following liver transplantation. This is the first step to developing a protocol that can allow patients to bypass intensive care following liver transplantation.