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

Context: On-table extubation after pediatric cardiac surgery has been increasingly considered a safe and effective strategy to reduce postoperative ventilation time. However, concerns regarding reintubation risk, patient selection, and variability in outcomes remain.

Objective: To systematically review the available literature on the effectiveness and safety of on-table extubation compared to off-table extubation in pediatric cardiac surgery. Primary outcomes were reintubation rate, mortality, intensive care unit (ICU) and hospital length of stay (LOS). Secondary outcomes were arterial pH, lactate, and PaCO₂ after surgery.

Data sources: MEDLINE, Cochrane Library, Web of Science, and Embase were searched from inception to January 8th, 2025, without language or date restrictions. Additional studies were identified through the backward snowballing technique.

Study selection: We included randomized controlled trials (RCTs) and observational studies comparing on-table and off-table extubation in pediatric patients (< 18 years) undergoing cardiovascular surgery. Studies with overlapping populations or conference abstracts were excluded.

Data extraction: Two independent reviewers screened studies completed a quality assessment, and extracted data.

Results: Twenty-nine studies (2 RCTs, 27 observational), including 9070 patients, met the eligibility criteria. On-table extubation was associated with lower reintubation rates in most studies, though findings were not consistent across all. Mortality rates were generally comparable between groups. ICU and hospital LOS were consistently shorter in the on-table group. Postoperative blood gas analyses showed a better arterial pH, lactate, and PaCO₂ profile in the on-table group. The risk of bias was elevated between observational studies.

Limitations: Selection bias was present, as the majority of studies were observational, and the decision for on-table extubation was largely based on clinician assessment of suitability and stability at the end of surgery. High heterogeneity across studies limited meta-analysis feasibility.

Conclusion: Although this systematic review suggests that on-table extubation may be associated with potentially better outcomes following pediatric cardiac surgery, no safe conclusions can be drawn about its benefit due to the high heterogeneity and potential high risk of bias of most included studies. Well-designed RCTs are needed to confirm the benefits and safety of on-table extubation and to guide appropriate patient selection.

Trial registration: International Prospective Register of Systematic Reviews (PROSPERO): CRD42025644238.