Early Versus Late Extubation After Pediatric Cardiac Surgery: A Systematic Review and Meta-analysis

Early extubation after pediatric cardiac surgery has been increasingly adopted as part of fast-track and enhanced recovery pathways, but its association with postoperative outcomes remains uncertain. The authors conducted a systematic review and meta-analysis of studies comparing early extubation (defined as extubation in the operating room or within 24 hours postoperatively) versus delayed extubation after pediatric cardiac surgery. Electronic databases were searched from inception through April 2024. Random-effects models were used to pool effect estimates for mortality, reintubation, and length-of-stay outcomes. Prespecified subgroup and sensitivity analyses were performed. Twenty-eight studies, including 37,995 children, were analyzed. Early extubation was associated with lower in-hospital mortality (odds ratio, 0.19; 95% confidence interval, 0.14-0.25); however, absolute mortality rates were low, and this association was vulnerable to confounding by indication and preferential selection of clinically stable patients for early extubation. Early extubation was also associated with lower reintubation rates and shorter intensive care unit and hospital lengths of stay. Associations were more consistent among older children than among neonates. In this predominantly observational evidence base, early extubation should be interpreted primarily as a marker of patient stability and institutional practice rather than a proven intervention that reduces mortality. Given the low to very low certainty of evidence, these findings are hypothesis-generating and may inform quality-improvement initiatives and future prospective studies, rather than definitive clinical guidance.