Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes*

Abstract

Objectives: The epidemiology of unplanned extubations (UEs) and associated adverse outcomes in pediatric cardiac ICUs (CICU). Design: Registry data (August 2014 to October 2020). Setting: Forty-five Pediatric Cardiac Critical Care Consortium hospitals. Patients: Patients receiving mechanical ventilation (MV) via endotracheal tube (ETT). Interventions: None. Measurements and Main Results: Fifty-six thousand five hundred eight MV courses occurred in 36,696 patients, with a crude UE rate of 2.8%. In cardiac surgical patients, UE was associated with longer duration of MV, but we failed to find such association in medical patients. In both cohorts, UE was associated with younger age, being underweight, and airway anomaly. In multivariable logistic regression, airway anomaly was associated with UE in all patients. Younger age, higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score category, longer duration of MV, and initial oral rather than nasal ETT are associated with UE in the surgical group, but we failed to find such associations in the medical group. UE was associated with a higher reintubation rate compared with elective extubation (26.8 vs 4.8%; odds ratio [OR], 7.35; 95% CI, 6.44–8.39; p < 0.0001) within 1 day of event. After excluding patients having redirection of care, UE was associated with at least three-fold greater odds for each of ventilator-associated pneumonia (VAP), cardiac arrest, and use of mechanical circulatory support (MCS). However, we failed to identify an association between UE and greater odds of mortality (1.2 vs 0.8%; OR, 1.48; 95% CI, 0.86–2.54; p = 0.15), but uncertainty remains. Conclusions: UE in CICU patients is associated with greater odds of cardiac arrest, VAP, and MCS. Cardiac medical and surgical patients in the CICU appear to have different explanatory factors associated with UE, and perhaps these may be modifiable and tested in future collaborative population research.

Editor’s Choice Articles for July

“…Perry T, Klugman D, Schumacher K, et al: Unplanned Extubation During Pediatric Cardiac Intensive Care: U.S. Multicenter Registry Study of Prevalence and Outcomes (8).…”

Unplanned Extubations in the Cardiac ICU: Are We Missing the Beat?*

“…Could nasal intubation be protective? In the study by Perry et al (5), children in the surgical cohort had a lower frequency of nasal intubations in the UE group (13.5%) when compared with children without UE (19%) with an adjusted odds ratio of 0.57 (95% CI, 0.46-0.72). However, this effect was not seen in the medical cohort.…”

“…Achieving a sustained low UE rate through quality improvement work is possible both in single centers and on a larger scale, although efforts in UE reduction in the CICU have thus far globally remained elusive (6,7). In 2020, the study by Klugman et al (6) of the Solutions for Patient Safety Collaboration (SPS), a centerline shift was noted in the PICU and neonatal ICU cohort but not the CICU, although their reported CICU UE rate was at 0.281 events per 100 ventilation days-much lower compared with the study by Perry et al (5). One of the current SPS goals is to reduce UEs over the next 2 years.…”

“…In critically ill neonates and children, UEs contribute to significant physiological instability including morbidity and mortality (1,3,4). Those hospitalized in the cardiac ICU (CICU) represent a particularly vulnerable subset of children who may suffer from additional hospital-acquired conditions as a result of UE, including cardiac arrest, ventilator-associated pneumonia (VAP), increased duration of IMV, and need for mechanical circulatory support (5)(6)(7)(8). The unique risk factors and outcomes of UEs in children with medical and surgical cardiac disease remain poorly understood.…”

“…In this issue of Pediatric Critical Care Medicine, the study by Perry et al (5) evaluated the UEs in critically ill children with cardiac disease. In this multicenter, retrospective cohort study, the authors used a large dataset from the Pediatric Cardiac Critical Care Consortium (PC 4 ) registry to describe the incidence of UEs in the CICU, including risk factors and consequential harm (5). The dataset included 36,696 patients who had either UE or planned extubation in the CICU from 45 hospitals in North America over 6 years (2014-2020).…”