From fast track to ultrafast track extubation in cardiac surgery: a systematic review

Background: This study aimed to evaluate interventions that facilitate rapid extubation in adult cardiac surgery patients, defined as extubation within six hours, three hours, or one hour post-surgery. Early extubation is a critical component of enhanced recovery pathways in cardiac surgery and plays an essential role in improving patient outcomes. Several strategies have been investigated, including the use of locoregional anesthesia techniques, dexmedetomidine, and adaptive support ventilation. Methods: A systematic review of randomized controlled trials (RCTs) was conducted, searching the Medline, Central, and Embase databases from January 2015 to May 2025. Studies were included if they compared interventions for rapid extubation and achieved extubation within at least one study group for more than 75% of patients. Fifty-seven trials were included in the review. Results: Out of the 57 trials, 42 studies reported extubation within six to three hours post-surgery. These results were predominantly associated with locoregional anesthesia techniques, particularly fascial blocks, as well as dexmedetomidine use and adaptive support ventilation. Eleven studies reported extubation within three hours and one hour, with the majority of these trials also involving fascial blocks. Among the 57 studies, four focused specifically on ultrafast track strategies. Notably, only one study assessing the erector spinae plane block achieved extubation within one hour in over 75% of patients, with a median extubation time of 10 minutes (range 10-120 minutes), compared to 60 minutes (range 10-225 minutes) in the control group (P=0.06). Conclusions: While ultrafast extubation is currently limited to select patients, it appears to be safe and effective when carefully applied. The study supports the use of various interventions for facilitating rapid extubation and highlights the importance of individualized patient selection. Further high-quality trials are needed to identify the most effective combinations of these interventions and to standardize protocols for broader clinical practice.