Characteristics Associated With Unplanned Extubations in a Surgical Intensive Care Unit

Abstract

Background Unplanned extubations can result in serious complications. Objectives To determine characteristics of patients and nurses and risk factors that affect extubations. Methods A retrospective exploratory design was used. Ram-say Sedation Scale scores, need for reintubation, time between intubation and extubation, use of sedation and analgesia in the preceding 48 hours, and use of restraints were collected on 31 patients in a surgical intensive care unit who had unplanned extubations. For nurses, data collected included years’ experience in nursing and as an intensive care nurse, professional credentials, and location at the time of extubation. Results All unplanned extubations were self-extubations; 15 required reintubation. Most patients had low levels of sedation in the hour preceding the extubation (mean Ramsay score, 2.42; SD, 1.06). Patients who needed reintubation had higher mean Ramsay scores (2.85; SD, 1.14) than patients who did not (2.00; SD, 0.86; P = .04). Ramsay scores correlated with need for reintubation (r=0.423; P=.03). Of the 31 patients, 27 (87%) were restrained at the time of extubation (χ2 = 17.06; df=1; P<.001). Among the nurses, 32.3% had less than 5 years’ experience in nursing, and 51.6% had less than 5 years’ experience in intensive care; 89% of extubations occurred when the nurse was away from the bedside. Sedative and analgesic doses in the 24 hours before extubation did not differ significantly from those in the 2 hours before extubation. Conclusions Levels of sedation and use of restraints are associated with unplanned extubations and need for reintubation.

Unplanned extubation in critically ill adults: clinical review

“…Increasing patient tolerance during intubation is a major indication for sedation (Woien et al, 2012). As expected, significantly more self-extubations have been reported in patients with low sedation level (Chevron et al, 1998;Moons et al, 2004;Curry et al, 2008). Especially agitated patients are more prone to selfextubation when inadequately sedated (Boulain, 1998;Yeh et al, 2004).…”

“…Nursing care for maintaining tube patency, fixation and placement, routine oral care, changing patient position, use of rotary beds and patient transport outside the ICU can be generally associated with accidental extubation (Christie et al, 1996;Yeh et al, 2004). As regards selfextubation, attending nurse's absence from bedside followed by decreased patient surveillance is the main nurse-associated risk factor (Yeh et al, 2004;Curry et al, 2008). Less experienced nursing personnel may encounter self-extubation more frequently (Yeh et al, 2004).…”

“…However, the effect of restraints on self-extubation prevention has been challenged. Significantly higher self-extubation incidence has been reported in restrained patients (Tung et al, 2001;Chang et al, 2008;Curry et al, 2008), while in countries where restraints are minimally used, selfextubation incidence is relatively low (Kapadia, 2001). Unfortunately, observational design does not allow distinguishing whether restraints are contributing to self-extubation or these are simply more commonly used in patients being at higher estimated risk for deliberately removing their tube.…”

“…Inadequate sedation (Moons et al, 2004;Curry et al, 2008) Midazolam use (Tung et al, 2001;de Groot et al, 2011) Improper tube fixation (Boulain, 1998) Improper physical restraint use (Yeh et al, 2004;Chang et al, 2008) Oral intubation (Boulain, 1998;Chevron et al, 1998)…”

Extubation and Reintubation of the Difficult Airway

“…Patients insufficiently sedated are at greater risk for deliberate selfextubation, 38 but those more heavily sedated are more likely to require reintubation. 39 Fastidious attention to securing and supporting the ETT and breathing circuit is essential. Self-extubation may occur during emergence from anesthesia, when the patient is confused, agitated, and distressed, which promotes premature extubation.…”