Early Extubation Following Pediatric Cardiac Surgery and Reintubation Risk

Background: Early extubation following pediatric cardiac surgery has emerged as a component of postoperative care, with potential benefits including reduced mechanical ventilation exposure and improved ICU resource utilization. However, concerns persist regarding its safety, particularly the risk of reintubation. Additionally, patients selected for early extubation may differ in perioperative characteristics and operative complexity, which may influence observed outcomes. Hypothesis: Early extubation following pediatric cardiac surgery would be associated with lower reintubation rates, while differences in cardiopulmonary bypass time may provide additional context regarding perioperative characteristics and operative complexity. Design and Methods: A systematic review and meta-analysis was performed in accordance with PRISMA guidelines. PubMed, Embase, and Cochrane databases were systematically searched from January 2000 through January 2026 for studies evaluating early extubation following pediatric cardiac surgery. Early extubation was defined as postoperative extubation within 6 hours. Two predefined analyses were performed to address variability in delayed extubation definitions across studies. The initial analysis included studies explicitly comparing extubation <6 versus >6 hours postoperatively. An expanded analysis additionally incorporated studies reporting delayed extubation cohorts generally involving postoperative mechanical ventilation for more than 24 hours, to minimize overlap between extubation strategies.The primary outcome was reintubation. Cardiopulmonary bypass time was additionally evaluated to characterize perioperative differences between extubation cohorts. Pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI) were calculated using random-effects models, and statistical heterogeneity was assessed using the I 2 statistic. Results: Five studies (n=4,240) were included in the primary analysis. Early extubation was associated with lower odds of reintubation (OR 0.15, 95% CI 0.09-0.26; I 2 =50%) and shorter CPB times (MD –44.66 min, 95% CI –53.83 to –35.49; I 2 =79%). In the expanded analysis (8 studies, n=4,480), early extubation remained associated with lower reintubation odds (OR 0.20, 95% CI 0.12-0.35; I 2 =53%) and shorter CPB times (MD –36.28 min, 95% CI –49.69 to –22.86; I 2 =92%). Conclusions: Early extubation following pediatric cardiac surgery was associated with lower odds of reintubation. Early extubation cohorts also demonstrated shorter cardiopulmonary bypass times, which may reflect underlying differences in perioperative characteristics and extubation candidacy that should be considered when interpreting these associations.