Different extubation protocols for adult cardiac surgery: a systematic review and pairwise and network meta-analysis.

Summary

This systematic review and network meta-analysis (12 studies, n=1,454) found that late extubation after adult cardiac surgery was associated with higher success and lower extubation failure than early or on-table extubation. Despite this, early extubation may retain cost-effectiveness and safety advantages, underscoring the need for individualized strategy selection.

Key Findings

• Pairwise meta-analysis: late extubation outperformed on-table immediate extubation for protocol success (RR 1.52, 95% CI 1.21–1.91).
• Network meta-analysis: late extubation showed lower failure risk than early extubation and on-table extubation (RR 0.76 and 0.22, respectively).
• SUCRA ranking favored late extubation (94%) as most effective for minimizing extubation failure.
• Early extubation may still be advantageous for cost-effectiveness and safety, highlighting the need for individualized decisions.

Clinical Implications

Consider late extubation as the default in patients at high risk of extubation failure, while weighing resource and cost advantages of early extubation for low-risk patients. Develop risk-stratified extubation pathways and monitor quality metrics (extubation failure, reintubation).

Limitations

• Heterogeneity in definitions and timing windows for early vs late extubation across studies.
• Limited number of studies and potential selection/publication bias; variable adjustment for confounders.

Future Directions

Prospective, multicenter RCTs with standardized extubation definitions and risk stratification are needed to balance failure risk against resource utilization and patient-centered outcomes.