Intraoperative Hemodynamic and Metabolic Stress as Determinants of Prolonged Intensive Care Unit Stay in Pediatric Liver Transplantation

Background: This study aimed to identify perioperative determinants of prolonged intensive care unit (ICU) stay in a consecutive cohort of pediatric liver transplant recipients, with emphasis on intraoperative hemodynamic and metabolic variables.

Methods: This retrospective, single-center cohort study included 112 consecutive pediatric patients who underwent orthotopic liver transplantation (LT). The primary outcome was ICU length of stay ≥7 days. A multivariable binary logistic regression model was constructed using preoperative and intraoperative variables exclusively, following formal multicollinearity assessment with cluster-based variable selection. Discriminative performance was assessed by receiver operating characteristic analysis with bootstrap-derived CIs.

Results: Thirty-two patients (28.6%) experienced prolonged ICU stay. In a model limited by a low events-pervariable ratio (EPV 4.0), 2 variables were associated with prolonged ICU stay: higher graft-to-recipient weight ratio (GRWR; odds ratio [OR] = 1.840, 95% CI: 1.087-3.114; P = .023) and lower preoperative hemoglobin (OR = 0.715, 95% CI 0.521-0.981; P = .038). Peak intraoperative lactate demonstrated moderate standalone discriminative performance (area under the curve 0.745; optimal threshold 6.0 mmol/L, sensitivity 59.4%, specificity 88.7%), without retaining significance in the multivariable model owing to collinearity. Prolonged ICU stay was associated with significantly higher rates of reintubation (40.6% vs. 9.0%; P < .001) and 30-day mortality (31.2% vs. 8.9%; P = .007).

Conclusion: Prolonged ICU stay in pediatric LT was associated with higher GRWR and lower preoperative hemoglobin. Peak intraoperative lactate showed moderate discriminative performance and a strong continuous association with ICU duration. These findings highlight perioperative correlates of ICU utilization that may inform risk stratification and warrant prospective evaluation.

Cite this article as: Şahin T, Kavaklı AS, Aydin A, et al. Intraoperative hemodynamic and metabolic stress as determinants of prolonged ICU stay in pediatric liver transplantation. Eurasian J Med. 2026, 58(4), 1516, doi: 10.5152/eurasianjmed.2026.261516.