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 Table of Contents  
EDITORIAL
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 59-60

Unplanned extubation in the pediatric intensive care unit: Alert, acknowledge, and avert


Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission18-Jan-2021
Date of Acceptance27-Jan-2021
Date of Web Publication10-Mar-2021

Correspondence Address:
Dr. Suresh Kumar Angurana
Department of Pediatrics, Division of Pediatric Critical Care, Advanced Pediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcc.jpcc_7_21

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How to cite this article:
Angurana SK. Unplanned extubation in the pediatric intensive care unit: Alert, acknowledge, and avert. J Pediatr Crit Care 2021;8:59-60

How to cite this URL:
Angurana SK. Unplanned extubation in the pediatric intensive care unit: Alert, acknowledge, and avert. J Pediatr Crit Care [serial online] 2021 [cited 2021 Apr 20];8:59-60. Available from: http://www.jpcc.org.in/text.asp?2021/8/2/59/311062



Unplanned extubation (UE) is defined as displacement of an endotracheal tube from the trachea at any time other than time chosen for planned extubation (PE) that is not intentional or ordered by a health-care provider. Adult literature showed that UEs are associated with increased in duration of mechanical ventilation and hospital stay, ventilator-associated pneumonia (VAP), and mortality.[1],[2] Recently, few pediatric studies described the UE and its causative factors including younger age, inadequate sedation, secretions, loose endotracheal tubes, restraints, staffing pattern, and bedside procedures.[3],[4],[5] In addition, UEs in children have been associated with significant morbidity including cardiovascular collapse (cardiac arrest in up to 20%), higher reintubation rates (49%–69%), and increased cost and length of stay, and increased mortality.[3],[4],[5],[6]

Despite the fact that UEs are common in pediatric intensive care units (PICUs) (0.5–2 UE events/100 ventilator days) and associated with increased morbidity and mortality,[3],[5],[7] the comprehensive studies evaluating the incidence, causative factors, and harms are lacking from Indian PICUs. In absence of such data, it may be difficult to formulate interventions or quality improvement initiatives to reduce the incidence of UEs among children and harms associated with it.

In this issue of Journal of Pediatric Critical Care, Kumar et al.[8] reported 39 children (1 month–18 years) with UE over a period of 6.5 years (January 2013 to May 2019) from a level-4 PICU. The rate of UE was 2.3% (39/1721) or 0.52 UE events/100 ventilation days. The most common reasons identified for UEs were inadequate sedation (61.5%, n = 24); endotracheal tube suctioning (12.8%, n = 5); one (2.6%) each while adjusting endotracheal tube, insertion of central venous catheter and Foley's catheter; and unexplained (17.9%, n = 7). The reintubation rate was 74.3% (n = 29) and most of the children were re-intubated within 2 h of UE. The common reasons for re-intubation were worsening respiratory distress (72.4%, n = 21), stridor (17.2%, n = 5), and apnea (10.3%, n = 3). The rates of VAP were higher in children who had UE and underwent re-intubation than VAP rate in PICU (11.4 vs. 8.7/1000 ventilator days, P = 0.54).[8]

The use of a combination of sedatives and analgesics, which is desirable in all mechanically ventilated children, was very conservative in children who had UE.[8] Despite the fact that 79% (n = 31) children were on full ventilatory support at the time of UE, very few of them were on appropriate combination of sedation and analgesia (midazolam and morphine/fentanyl; or dexmedetomidine) (25.6%, 10/39). Also, the mean Ramsay sedation score (RSS) was 2.44 and majority (61.5%, n = 24) of children had RSS of 1 or 2 at the time of UE despite the target RSS of 3-4. As highlighted by the authors, the inadequate sedation (and analgesia) was the most common cause of UE in this cohort.[8] The younger age group is more predisposed to develop UE.[3],[5] This has been highlighted by the fact that the median age of children with UE was 14 months and 71.8% (n = 28) were <2 years. In contrast, those who underwent PE, only 49.4% (n = 850) were aged <2 years (P = 0.006).[8] The fact that 25.6% (n = 10) cases did not require re-intubation highlights that these children were either ready for weaning, spontaneous breathing trial, and extubation.The use of high-flow oxygen therapy (nonrebreathing mask and high-flow nasal cannula) obviated the need for re-intubation.[8]

Recently, Klugman et al.[7] in a multicenter quality improvement initiative involving 43 pediatric, neonatal, and cardiac intensive care units demonstrated that implementation of a quality improvement bundle including standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses resulted in 24.1% reduction in UE events (from 1.135 UEs/100 ventilator days to 0.862 UEs/100 ventilator days) and reduction in cardiovascular collapse events associated with UE by 36.6% (from 0.041 UEs/100 ventilator days to 0.026 UEs/100 ventilator days).

All health-care providers working in PICUs must remain alert about the risk of UE, identify the high-risk cases for UE, acknowledge that UE can happen in PICUs, make an effort to identify the causes of UE (root cause analysis), and utilize appropriate interventions to avert UE. The appropriate and adequate use of sedation and analgesia, right patient selection for sedation and analgesia, use of objective criteria to guide the adequate level of sedation and analgesia, uniform and adequate securement method for endotracheal tube, adequate training of health-care providers in maintaining endotracheal tube during procedures and otherwise, adequate nurse: patient ratio, timely weaning and liberation from mechanical ventilation, and implementation of UE quality improvement bundle are some of the important key points that can help us in reducing the incidence of UE in PICU and poor outcome associated with it.[3],[4],[5],[7] To emphasize the points highlighted by the authors, there is need of multi-centric studies from India highlighting the incidence of UEs in Indian PICUs, risk factors, and harms associated with UEs. Also, there is need for uniform standard of care of the intubated children and quality improvement initiatives to reduce the incidence of UEs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Krinsley JS, Barone JE. The drive to survive: Unplanned extubation in the ICU. Chest 2005;128:560-6.  Back to cited text no. 1
    
2.
Gao F, Yang LH, He HR, Ma XC, Lu J, Zhai YJ, et al. The effect of reintubation on ventilator-associated pneumonia and mortality among mechanically ventilated patients with intubation: A systematic review and meta-analysis. Heart Lung 2016;45:363-71.  Back to cited text no. 2
    
3.
Fitzgerald RK, Davis AT, Hanson SJ, National Association of Children's Hospitals and Related Institution PICU Focus Group Investigators. Multicenter analysis of the factors associated with unplanned extubation in the PICU. Pediatr Crit Care Med 2015;16:e217-23.  Back to cited text no. 3
    
4.
Marcin JP, Rutan E, Rapetti PM, Brown JP, Rahnamayi R, Pretzlaff RK. Nurse staffing and unplanned extubation in the pediatric intensive care unit. Pediatr Crit Care Med 2005;6:254-7.  Back to cited text no. 4
    
5.
Censoplano NM, Barrett CS, Ing RJ, Reichert K, Rannie M, Kaufman J. Achieving sustainability in reducing unplanned extubations in a pediatric cardiac ICU. Pediatr Crit Care Med 2020;21:350-6.  Back to cited text no. 5
    
6.
Lucas da Silva PS, Fonseca MCM. Incidence and risk factors for cardiovascular collapse after unplanned extubations in the pediatric ICU. Respir Care 2017;62:896-903.  Back to cited text no. 6
    
7.
Klugman D, Melton K, Maynord PO, Dawson A, Madhavan G, Montgomery VL, et al. Assessment of an unplanned extubation bundle to reduce unplanned extubations in critically Ill neonates, infants, and children. JAMA Pediatr 2020;174:e200268.  Back to cited text no. 7
    
8.
Kodicherla VV, Shaikh F, Duvvana PK, Yerra A, Reddy Y, Dekate P, et al. Clinico-etiological profile of children who had unplanned extubation and subsequent re-intubation in level-4 pediatric intensive care unit. J Pediatr Crit Care 2021;8:67-73.  Back to cited text no. 8
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