BACKGROUND: With the advancement of ultra-fast track anesthesia, early extubation following cardiac surgery has become a prevailing trend. While there are significant benefits associated with early extubation, its high failure rate warrants further investigation, and the effectiveness of various extubation strategies in cardiac surgery still requires validation. METHODS: An extensive literature search was performed in the PubMed, Scopus, Embase, and Web of Science databases, encompassing studies without language restrictions. Eligible studies were those that compared the outcomes of various extubation strategies. RESULTS: Primary outcome was the success rate of the extubation protocol. Secondary outcomes were time to extubation, intensive care unit (ICU) length of stay (LOS), complications and mortality rate. Data from 12 studies, which included a total of 1454 participants, were included in the analysis. The pairwise meta-analysis revealed that late extubation was significantly more effective than immediate extubation strategies (relative risk [RR] = 1.52, 95% confidence interval [CI] = 1.21-1.91, P = 0.0001). In the network meta-analysis (NMA), the late extubation protocol was associated with a significantly lower risk of extubation failure compared to early extubation and extubation on the table (RR = 0.76, 95% CI: 0.5-1.16
RR = 0.22, 95% CI: 0.05-0.91). Furthermore, according to the SUCRA plot, late extubation was ranked as the most effective strategy for reducing extubation failure (94%). CONCLUSIONS: Our findings indicate that a late extubation strategy, as opposed to early (within a specified time frame) or immediate extubation, is correlate with a substantially higher rate of successful extubation. Despite this, the early extubation strategy seems to offer better cost-effectiveness and safety profiles. The selection of an appropriate extubation strategy should be personalized, taking into account the patient's preoperative characteristics and the circumstances encountered during surgery. TRIAL REGISTRATION: The study protocol adheres to the PRISMA statement and checklist. The protocol was registered at PROSPERO (CRD42024529051).