Ultra-fast tracking is defined when extubation done in operating table This was practised routinely with good results after paediatric cardiac surgery in 1970s because of non-availability of proper paediatric ventilators and safe sedative and hypnotics. But after the advent of fentanyl group of drugs and paediatric ventilators post op ventilation became a routine procedure since 1990. [1] Again since 2000 at many centres in the world on table extubation started after paediatric cardiac surgery. This is mainly because of less ventilator associated complications, early feeding and ambulation and quick discharge. [2], [3]. The present study was aimed at the establishment of safety and efficacy of that ultra-fast track protocol after paediatric open heart surgery in the existing set up of our institution where there is no dedicated postop paediatric cardiac surgery ICU.

Study design: Retrospective analytical, post-facto observational study Place of study: Department of Cardiothoracic Surgery, NRS Medical College and Hospital, Kolkata, West Bengal Period of study: Retrospective data collection/review: April–May 2026; study patients operated during January–March 2025 Study Population: Paediatric patients undergoing surgical repair of simple congenital heart diseases (ASD/VSD) under cardiopulmonary bypass Sample size: 12 patients — 6 in the ultra-fast-track/on-table extubation group and 6 in the conventional/ITU extubation control group Inclusion Criteria: 1. Paediatric patients undergoing surgical repair of simple congenital heart disease (ASD or VSD). 2. Patients operated during January–March 2025. 3. Patients without associated congenital cardiac anomalies. 4. Patients without pulmonary arterial hypertension (PAH). 5. Patients without significant comorbidities. 6. For the ultra-fast-track group, patients who fulfilled criteria for safe extubation on the operating table after completion of surgery. Exclusion criteria: 1. Patients with associated congenital cardiac anomalies. 2. Patients with pulmonary arterial hypertension. 3. Patients with significant medical comorbidities. 4. Patients with significant postoperative bleeding or haemodynamic instability. 5. Patients with inadequate rewarming after cardiopulmonary bypass. 6. Patients with unacceptable blood-gas status or haemoglobin level preventing early extubation. Data Collection: Data was recorded in departmental registers, perfusionists, personal and RBSK records. Such records on a period of 3 months (Jan to March 2025) were utilised for this post facto observational study. Statistical Analysis: Data were collected from departmental records and entered into Microsoft Excel and analysed using appropriate statistical software. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequency and percentage. The ultra-fast-track/on-table extubation group and the conventional ITU-extubation control group were compared with respect to demographic, perioperative and postoperative variables. For comparison of continuous variables, the independent samples t-test was used for normally distributed data, while the Mann–Whitney U test was used for non-normally distributed data. Categorical variables were compared using the Chi-square test or Fisher’s exact test, as appropriate. A p-value ≤0.05 was considered statistically significant. Given the small sample size of 12 patients, Fisher’s exact test was preferentially used where expected cell frequencies were small. Limitations: It is a single center study wth less number of patients. Moreover it is purely a post facto observational study with non-randomisation but consecutively selected samples. Conflict of interest: None Informed consent: Not required being a review study Funding: None.

Table 1: Comparison of Demographic and Operative Variables Between Ultra-Fast-Track and Fast-Track Groups Demographic & Operative Variable Ultra-Fast Track Protocol (On Table Extubation) Fast Track Protocol (Extubation ≤ post op 6 hours) t Test Mean ± Standard Deviation Mean ± Standard Deviation P Value Significant Age (Years) 6.50 ± 2.061 8.83 ± 3.184 0.1 Not Significant Body Wt. (Kg) 16.83 ± 4.26 18.00 ± 6.78 0.364 Not Significant Hb (gm/dl) 10.31 ± 1.226 10.116 ± 1.763 0.42 Not Significant X Clamp Time (Min) 45.833 ± 16.106 33.666 ± 9.374 0.088 Not Significant Bypass time (Min) 92.333 ± 20.885 75 ± 12.355 0.071 Not Significant Table 2: Comparison of Postoperative Recovery Variables between Ultra-Fast-Track and Fast-Track Groups Post Op Variable Ultra-Fast Track Protocol (On Table Extubation) Fast Track Protocol (Extubation ≤ post op 6 hours) t Test Mean ± Standard Deviation Mean ± Standard Deviation P Value Significant Fast Enteral Feed After Operation 4.5 ± 0.763 11.166 ± 1.343 <0.001 Significant Post- Op Hospital stay (Day) 2.333 ± 0.745 3.66 ± 0.945 0.016 Significant Table 1 compares the demographic and operative characteristics of patients in the ultra-fast-track (on-table extubation) and fast-track (extubation within 6 hours postoperatively) groups. The mean age was 6.50 ± 2.061 years in the ultra-fast-track group compared with 8.83 ± 3.184 years in the fast-track group, with no statistically significant difference (p=0.100). Similarly, the mean body weight was 16.83 ± 4.26 kg and 18.00 ± 6.78 kg, respectively (p=0.364). Mean haemoglobin levels were comparable between the groups (10.31 ± 1.226 g/dL vs. 10.116 ± 1.763 g/dL; p=0.420). The mean aortic cross-clamp time was 45.833 ± 16.106 minutes in the ultra-fast-track group and 33.666 ± 9.374 minutes in the fast-track group (p=0.088). Similarly, mean cardiopulmonary bypass time was 92.333 ± 20.885 minutes versus 75.00 ± 12.355 minutes, respectively (p=0.071). When compared those two groups in terms of preop (Demographic) and operative variability, there was no significant difference which proved that choice of patients in both groups were identical and ideal to compare the effect of extubation on them subsequently. Table 2 demonstrates a significant difference in early postoperative recovery between the two groups. The mean time to initiation of enteral feeding was markedly shorter in the ultra-fast-track group, at 4.50 ± 0.763 hours, compared with 11.166 ± 1.343 hours in the fast-track group. This difference was highly statistically significant (p<0.001), indicating substantially earlier feeding following on-table extubation. Similarly, the mean postoperative hospital stay was significantly shorter in the ultra-fast-track group (2.333 ± 0.745 days) compared with the fast-track group (3.66 ± 0.945 days; p=0.016).

It has been observed that for post op management of children undergoing surgery for CHD, every hour of mechanical ventilation increases the risk which gets compounded with the addition of sedation. . Since 2000 centres in many countries started on table extubation under ultra-fast track protocol after paediatric cardiac surgery and all continued it as a routine. Such centres are doing this procedure on most of their patients (79 to 90 %) with successful outcome, shorter hospital stay, and less use of hospital resources. [2], [4], [5], [6], [7]. Likewise the present study also support good outcome of ultra-fast track protocol with zero mortality and significant early discharge.

It can be concluded in our study that ultra-fast track protocol is a safe and a feasible option. It is desirable because of early recovery and discharge which also support increased patient turnover and related possible cost containment.

1. Klauwer D.,Neuhaeuser C.,Thul J.,Zimmermann- A Practical Handbook on Pediatric Cardiac Intensive Care Therapy , Springer 2019 2. Garg R K, Thareen J K, Mehmood A et al Fast tracking after repair of congenital heart defects. IJTCVS (Jan 2021)37(Suppl 1): s183-189 3. Garg R, Rao S, John C, et al. Extubation in the operating room after cardiac surgery in children: a prospective observational study with multidiscipliniary coordinated approach. J Cardiothoracic Vasc Anaesthesia. 2014;28:479-87 4. Mittnacht AJC,Thanjan M, Srivastava S, et al. Extubation in the operating room after congenital heart surgery in children . J Thoracic Cardiovascular Surgery 2008;136:88-93 5. Harris KC,Holowachuk S,Pitfield S , et al .Should early extubation be the goal for children after congenital cardiac surgery ? J Thoracic Cardiovascular Surgery. 2014;148:2642-8 6. Bichell DP. Commentary: mechanical ventilation: a toxic asset. J Thoracic Cardiovascular Surgery. 2019;157:1599-600 7. Akhtar MI,Momeni M, Szekely A et al . Multicenter international survey on the clinical practice of ultra fast track anaesthesia with on table extubation in paediatric congenital cardiac surgery. J Cardiothorac Vasc Anesth.2019;33:406-15.