First, were there predefined protocols or departmental guidelines for extubation of liver transplant recipients, or were the criteria determined retrospectively [1-3]? Second, how was “fully awake” defined? Was an objective measure, such as the Bispectral Index or Sedation Scale, used? Third, how was the absence of residual neuromuscular blockade confirmed? It would be helpful is the authors could clearly describe the type, dose, and route of administration of neuromuscular blocking agents and reversal agents, and how recovery was monitored [4]. Fourth, were the specified parameters (e.g., tidal volume ≥ 5 ml/kg, respiratory rate ≤ 30/min, SpO₂ ≥ 95%, and FiO₂ 0.5) sufficient for extubation in liver transplant recipients? Fifth, was adequate acid-base balance established before extubation? Specifically, was pH > 7.25 considered sufficient or did it require correction before extubation [5]? Sixth, which post-extubation oxygenation method was used (e.g., high-flow nasal cannula, face mask, or nasal catheter)? We also note that the paper only discusses delayed extubation. Were there any extubation failure cases? If so, were they related to clinical factors or logistical issues, such as surgeon fatigue or intensive care unit staffing shortages [1-3]?

Ultimately, this article is a retrospective study. As liver transplantation recipients are more likely to have multiorgan disturbance or failure than general surgical patients, it should be applied more strictly with objective symptoms and signs. In addition, if early and delayed extubation are performed, extubation should be applied with clear criteria and strategies for airway and respiratory care to prevent extubation failure. The article does not list any specific criteria, except anesthesiologist experience for extubation after liver transplantation. Therefore, we wish to highlight the following: “While anesthetic principles for patient safety may be similar across surgeries, high-risk procedures such as liver transplantation require more individualized and meticulous strategies.”