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.