Operating Room Extubation After Cardiac Surgery: A Promising Practice or a Product of Selection Bias?

Extubation practices after cardiac surgery have increasingly shifted toward earlier strategies, including operating room extubation (ORE), although evidence regarding safety and outcomes remains mixed. On November 1, 2024, our center implemented a protocol requiring systematic consideration of ORE for all elective cases involving cardiopulmonary bypass, with prospective data collection through June 2025. Among 628 cases, 171 patients (27%) were extubated in the operating room, with a consistent monthly rate of approximately 30%. Patients had a median age 62 years and a relatively low burden of major comorbidities. Reintubation occurred in 5 patients (2.9%) and all patients survived to 30 days. Median intensive care unit stay was shorter for ORE patients compared with all elective cardiac surgery patients (25.5 vs 38.2 hours, respectively), while hospital stay was similar (5 days). These results likely reflect selection bias rather than causality. Nonetheless, they demonstrate the feasibility and safety of a standardized ORE protocol, supporting the need for a multicenter randomized trial to establish efficacy and define optimal patient populations.