Abstract
Background:
Unplanned extubation (UE) is associated with heighten care activity, 1 and insufficient intravenous sedation. 2 We evaluated UE characteristics in our patients managed by daily sedation interruptions (DSI) targeted light sedation and spontaneous breathing trials (SBT).
Methods:
UE monitoring began in 2014 as a quality of care concern. Data collection included timing (Day: 07:00-15:00, Evening: 15:01-23:00, Night: 23:01-06:59), sedation and mechanism. Sedation was evaluated using Richmond Agitation and Sedation Score (RASS). Data is presented as median [IQR] and analyzed using Mann-Whitney U-tests or Fisher Exact test. Alpha was set at 0.05.
Results:
From January 2014 to December 2017 there were 96 UEs (2.3% incidence) : 95% were subject-initiated, 80% were males, 77% had restraints in place and 49% occurred during care activities (43% during SBT/DSI, 6% bedside procedures). Intravenous sedation was used in 71% of subjects: 33% propofol (30 [20, 50] mg/kg per min), 27% Precedex (1.00 [0.60, 1.50] µg/kg/h), 10% dual agents; whereas 33% received Fentanyl of 50 [50, 138] µg/h. Pre-UE RASS was 0 [-1, 1]. UE's occurred at 2 [1, 5] days of mechanical ventilation (MV); with 39% on day and night shifts, and 22% on evening shift. The 48 h re-intubation rate was 38%. At the time of UE most subjects met weaning readiness criteria; only PEEP distinguishing those requiring re-intubation (Table). Post-UE incidence of cardiovascular or respiratory instability was 8% and 19% respectively, yet these subjects accounted for only 44% of re-intubations. Hospital mortality was 8% and did not distinguish those requiring re-intubation from those who did not (11% vs.6.6%; RR: 1.69 (0.45-6.4) P = 0.46).
Conclusions:
In 63% of our subjects UE occurred during periods when sedative effects were minimal or absent, 87% met weaning readiness criteria and 62% did not require re-intubation and MV. More than half (56%) of those experiencing cardiorespiratory instability following UE also did not require such support.
1. Tindol GA, et al. Unplanned Extubations. Chest 1994;105:1804-1807. 2. Boulain T, et al. Unplanned extubations in the adult intensive care unit. AM J Respir Care Med 1998;157:1131-1137.
Key: PSV = pressure support ventilation, CMV = continuous mechanical ventilation, FiO2 = inspired oxygen fraction, SpO2 = pulse oxygen arterial saturation. View all access options for this article.
Re-Intubated (48h)
Not Re-Intubated
P
Mode (PSV/CMV)
53% / 47%
53% / 47%
1
FiO2
0.40 [0.40, 0.50]
0.40 [0.40, 0.40]
0.06
PEEP (cmH2O)
8 [5, 8]
5 [5,8]
0.012
VE (L/m)
9.3 [6.6, 11.1]
7.3 [6.2, 9.9]
0.07
SpO2%
97 [95, 99]
100 [97, 100]
0.67
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