Early Extubation After Pediatric Liver Transplantation: From Baseline Vulnerability to Perioperative Readiness

Early extubation after pediatric liver transplantation (PLTx) is increasingly incorporated into enhanced-recovery pathways, yet definitions, selection criteria, and outcome reporting remain inconsistent. This narrative review synthesizes evidence identified through PubMed/MEDLINE (January 2000 through August 2026), citation screening, and supplementary screening of recent reports. Immediate extubation denotes tracheal extubation in the operating room, whereas early extubation has been defined through 24 postoperative hours; delayed extubation and prolonged mechanical ventilation are similarly heterogeneous. The available evidence informs a dynamic framework in which preoperative characteristics define baseline vulnerability, the intraoperative course reflects whether that vulnerability has been overcome or amplified, and the early postoperative course validates the decision. Young age, low body weight, growth failure, or higher disease-severity scores may increase risk but should not function as absolute exclusions; conversely, low scores may underestimate disease-specific risk in metabolic disorders. Direct readiness indicators include effective ventilation, neurological and quantitative neuromuscular recovery, normothermia, stable hemodynamics without escalating vasoactive support, controlled bleeding, satisfactory abdominal closure, and improving acid–base status and lactate clearance. Early extubation is associated with shorter intensive-care and hospital stays in selected cohorts, but causality remains uncertain because evidence is predominantly retrospective and single-center. Standardized definitions and prospective multicenter validation are required.