Immediate vs delayed extubation after pediatric liver transplantation: a systematic review and meta-analysis

Immediate extubation (IE) in the operating room following orthotopic liver transplantation (OLT) is increasingly adopted in adults but pediatric evidence remains limited. This systematic review and meta-analysis aimed to identify factors associated with IE and compare outcomes between IE and delayed extubation (DE) after pediatric OLT. MEDLINE, EMBASE, Scopus, CINAHL, Web of Science, and Cochrane Library were searched from inception to October 30, 2025. Studies comparing IE and DE in pediatric OLT recipients were included. Outcomes included reintubation, mortality, thrombosis, reoperation, tracheostomy, PICU, and hospital length of stay (LOS). Random-effects meta-analysis was pre-specified for all outcomes; sensitivity, meta-regression, and subgroup analyses were performed. Risk of bias was assessed with ROBINS-I. Twelve retrospective single-center studies comprising 1323 patients (1158 unique children after accounting for two center-level cohort overlaps) were included. IE was associated with lower odds of reintubation (OR 0.32, 95% CI 0.17-0.59) and mortality (OR 0.35, 95% CI 0.18-0.68); both estimates were confirmed by a correction-free Peto odds ratio (0.29 and 0.31, respectively). No significant differences were observed for thrombosis or reoperation. IE was associated with shorter PICU LOS (SMD - 0.88, 95% CI - 1.39 to - 0.37), hospital LOS (SMD - 1.16, 95% CI - 2.00 to - 0.31). Donor-type subgroup analyses showed effect sizes in the same direction as the overall analysis for PICU and hospital LOS, but none of the within-subgroup estimates reached statistical significance. Meta-regression identified intraoperative transfusion differences as predictor of hospital LOS (β =  - 0.045, p = 0.006, R² = 57.1%), a pattern more consistent with confounding by indication than with a beneficial mechanism of transfusion itself.

IE was associated with lower reintubation, mortality, and shorter LOS in pediatric OLT, but these findings derive exclusively from retrospective studies at high risk of selection bias, and causality cannot be established. Children undergoing IE were likely older and in better preoperative condition; hospital LOS findings are particularly susceptible to confounding. Prospective multicenter studies are needed to confirm these outcomes benefit.

• Delayed extubation with prolonged mechanical ventilation has been standard after pediatric orthotopic liver transplantation. • Immediate extubation in the operating room is increasingly used after adult liver transplantation experiences. • Pediatric evidence on immediate extubation comes from single-center retrospective studies.

• This meta-analysis of 12 studies found immediate extubation associated with lower reintubation, mortality, and shorter length of stay. • These associations likely reflect selection bias rather than a proven causal benefit. • Immediate extubation appears feasible and safe in selected children, but prospective multicenter studies are needed to determine patients benefiting from this approach.