Are There Effective, Evidence-Based Strategies That Can be Implemented in Practice to Prevent Unplanned Extubations?
Abstract & Commentary
Are There Effective, Evidence-Based Strategies That Can be Implemented in Practice to Prevent Unplanned Extubations?
By Linda L. Chlan, RN, PhD, School of Nursing, University of Minnesota, is Associate Editor for Critical Care Alert.
Dr. Chlan reports that she receives grant/research support from the National Institutes of Health.
Synopsis: Recommendations from the small number of lower-quality studies cited in this review article that examined strategies to prevent unplanned endotracheal extubations include: continuous quality improvement programs to standardize care including weaning readiness; application of physical restraints only when deemed necessary to prevent device removal; standardized practices for securing the endotracheal tube; sedation protocols; and appropriate nurse/patient ratios.
Source: da Silva Lucas PS, Fonseca MC. Unplanned endotracheal extubations in the intensive care unit: Systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg 2012;114:1003-1014.
The purpose of this article was to provide a systematic review and critical appraisal of the literature on the incidence and risk factors for unplanned endotracheal extubations, factors associated with reintubations, and outcomes of unplanned extubations. Several evidence-based recommendations were presented to prevent unplanned extubations.
The search strategy used by the two Brazilian authors included searching a number of key databases from January 1950 to May 2011, with an extensive list of key search terms pertaining to adult ICU patients. Criteria for selection of studies included the incidence of unplanned extubations, outcomes and risk factors of unplanned extubations, the incidence of reintubations, and strategies to prevent unplanned extubations. A variety of study designs were considered, including cohort, case-control, or cross-sectional. The Newcastle-Ottawa Scale1 was used to assess the quality of nonrandomized studies. The Oxford Centre for Evidence-based Medicine's Level of Evidence2 was used for assessing grades of recommendation. The search initially yielded 44,766 potentially relevant studies, 103 of which were reviewed. From this number, 50 studies met the inclusion criteria. Overall, the papers included in the review were deemed to be of lower methodological quality as no randomized trials were included.
The incidence of unplanned extubations is reported in the literature as either the number per 100 ventilated patients, or as the number per 100 days of mechanical ventilation. This varying method of reporting a key statistic is problematic. Overall, over the last 10 years the median rate of unplanned extubation was 7.3 per 100 ventilated patients, or a median of 0.9 unplanned extubations per 100 intubation days. A majority of unplanned extubations were patient self-extubations. Risk factors associated with unplanned extubations among the studies reviewed were inconsistent across the studies. Some studies reported that patients who were restless or agitated self-extubated more often, whereas others reported patients at a higher level of consciousness self-extubated. Patients who received midazolam had a greater risk for self-extubations, as did those with a higher acuity level, and those without a nurse at the bedside. The application of physical restraints was found in 25-87% of patients who self-extubated.
Not surprisingly, complications of unplanned extubations include airway and vocal trauma, respiratory distress, tachycardia, and emesis. Reintubation rates were 1.8-88% overall. Outcomes of unplanned extubations included prolonged mechanical ventilation and longer ICU and hospital stays, particularly in those patients who required reintubation, which was associated with increased mortality. Very few studies included preventive measures for reducing unplanned extubations. Most effective were quality improvement programs targeted with staff education, surveillance, and management of high-risk patients.
Physical restraints do not prevent self-extubation and should only be used when other strategies to prevent device removal have been exhausted. Methods for safely securing the endotracheal tube should be used on all patients. The role of sedation remains controversial. Patients who are sedated still self-extubate, which the authors concluded was an indicator of inadequate sedation. Given that most patients tolerate unplanned extubations, weaning readiness should be actively assessed in patients. The role of appropriate nursing staff ratios and experience remains unclear in the prevention of unplanned extubations.
COMMENTARY
This well-done, high-quality systematic review critically appraises the state of the science in regards to the incidence, risk factors, outcomes, and preventive strategies surrounding unplanned endotracheal extubations. While unplanned extubation can be a serious occurrence, most patients who self-extubate do not require re-intubation. Most times, these patients were ready to wean. A complicating factor in this review is that some studies report unplanned extubation rates per 100 patients, while others report them per 100 patient days. A standard report metric is needed.
The role of sedation and physical restraints in unplanned extubations remains unclear. This author does not agree with the comments made by da Silva Lucas and Fonseca that inadequate sedation is tied to self-extubations. Given the complexity of factors, delirium and agitation may play a prominent role. Patients who are anxious may require a different approach to symptoms management. Tailored sedative regimens are needed for mechanically ventilated patients. Likewise, the use of physical restraints does not prevent self-extubation. The literature demonstrates that the application of physical restraints can contribute to patient agitation and thus lead to self-extubation. The practice of routine application of physical restraints to prevent treatment interference is unwarranted and needs to cease.
Many of the recommendations for prevention of unplanned extubations are based on sound clinical practice, such as implementing standardized protocols for weaning readiness and securing endotracheal tubes. Clinicians are advised to actively include these strategies in their practice to prevent unplanned extubations.
References
- Wells GA, et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analyses. www.ohri.ca/programs/clinical_epidemiology/oxford.htm.
- Oxford Centre for Evidence-based Medicine. Levels of evidence and grades of recommendation. www.cebm.net/index.aspx?o=1025.
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