Association of Prophylactic Corticosteroids with Post-Extubation Outcomes in Pediatric Cardiac Critical Care: A Retrospective Propensity-Weighted Cohort Study

Background/Objectives: Post-extubation stridor (PES) is common in pediatric critical care and may contribute to extubation failure, particularly in children with heart disease. Prophylactic corticosteroids are frequently used before extubation, but their benefit in pediatric cardiac patients remains uncertain. We evaluated the association of prophylactic corticosteroids with PES and extubation failure and explored whether PES mediated any association with failure. Methods: We performed a retrospective, single-center, observational cohort study of extubation events in a pediatric cardiac critical care unit from July 2016 to June 2024. Exposure was prophylactic intravenous corticosteroids before planned extubation, most commonly dexamethasone (0.15–0.5 mg/kg per dose) or methylprednisolone (1–2 mg/kg per dose), administered 6–24 h before extubation in single- or multi-dose regimens. The primary outcome was clinically defined PES; the secondary outcome was extubation failure, defined as reintubation within 48 h. Confounding was addressed using propensity scores with inverse-probability weighting after common-support restriction. Causal interpretation of the weighted and mediation estimates was considered conditional on the no-unmeasured-confounding (ignorability) assumption. Subgroup analyses were stratified by PES status, and exploratory mediation analysis used structural equation modeling. Results: Among 494 extubation events, prophylactic corticosteroid use was not associated with lower odds of PES after weighting (OR 1.06, 95% CI 0.53–2.10) or extubation failure (OR 0.49, 95% CI 0.19–1.24). Among patients with PES, corticosteroid use was associated with a non-significant reduction in extubation failure (OR 0.70, 95% CI 0.14–3.43). Exploratory mediation analysis, interpreted under the ignorability assumption, did not support PES as a meaningful mediator. Conclusions: In this single-center cohort, prophylactic corticosteroid use was not associated with reduced PES or extubation failure. The findings do not support clinically defined PES as a key mediator of any potential treatment effect. Prospective studies are required for confirmation.