To evaluate the feasibility, safety, and early outcomes of a standardized operating room extubation (ORE) protocol implemented for elective cardiac surgery patients requiring cardiopulmonary bypass.

A prospective observational cohort study with systematic protocol implementation and data collection.

A single academic medical center.

Six hundred twenty-eight patients undergoing elective cardiac surgery with cardiopulmonary bypass between November 2024 and June 2025.

Implementation of a protocol requiring systematic consideration of ORE for all eligible patients, with 171 patients (27%) receiving ORE and 457 patients receiving conventional intensive care unit (ICU) extubation.

Primary outcomes included unadjusted ORE utilization rates, reintubation rates, 30-day mortality, ICU length of stay, and hospital length of stay. On average 28% of eligible cases were extubated each month. Patients selected for ORE were relatively young (median age 62 years) with a low comorbidity burden. All ORE patients survived for 30 days. Reintubation occurred in 5 patients (2.9%). Median ICU stay was shorter for ORE patients compared with the overall cohort (26 v 38 hours), while median hospital stay was similar between groups (5 days).

A standardized ORE protocol demonstrated feasibility and safety in selected cardiac surgery patients, with low reintubation rates, zero 30-day mortality, and reduced ICU length of stay. However, these encouraging outcomes likely reflect patient selection based on clinical judgment and cannot establish comparative efficacy relative to early ICU extubation. A multicenter randomized controlled trial is needed to determine efficacy and define optimal patient populations for ORE.