On-Table Extubation After Pediatric Cardiac Surgery: A Systematic Review

Area of Science:

• Pediatric Cardiac Surgery
• Anesthesiology
• Critical Care Medicine

Background:

• On-table extubation is increasingly considered for pediatric cardiac surgery to shorten ventilation time.
• Concerns persist regarding reintubation risk, patient selection, and outcome variability.

Purpose of the Study:

• To systematically review the literature on the effectiveness and safety of on-table versus off-table extubation in pediatric cardiac surgery.
• Primary outcomes: reintubation rate, mortality, ICU and hospital length of stay (LOS).
• Secondary outcomes: postoperative arterial pH, lactate, and PaCO2.

Main Methods:

• Systematic literature search of MEDLINE, Cochrane Library, Web of Science, and Embase up to January 2025.
• Included randomized controlled trials (RCTs) and observational studies of pediatric patients (<18 years) undergoing cardiovascular surgery.
• Two independent reviewers performed study screening, quality assessment, and data extraction.

Main Results:

• Twenty-nine studies (2 RCTs, 27 observational) with 9070 patients were included.
• On-table extubation was associated with lower reintubation rates in most studies, shorter ICU and hospital LOS, and better postoperative blood gas profiles.
• Mortality rates were comparable; however, risk of bias was elevated in observational studies.

Conclusions:

• Selection bias is present due to the observational nature of most studies and clinician-based decisions for on-table extubation.
• High heterogeneity across studies limits definitive conclusions and meta-analysis feasibility.
• Well-designed RCTs are essential to confirm the benefits and safety of on-table extubation and guide patient selection.