Unplanned extubation

OVERVIEW

  • Unplanned extubation of mechanically ventilated patients is relatively common ( 0·5% to 14·2% of ICU patients in most studies, higher in a few outliers)
    • Self-extubation refers to the patient’s action, who deliberately removes the endotracheal tube (most common type of unplanned extubation, typically occur at night)
    • Accidental extubation is attributed either to personnel’s inappropriate manipulation of the tube during patient care or to a non-purposeful patient’s action, e.g. coughing (mostly occur in the morning)
  • The event may occur without significant sequelae, but can also be life-threatening

RISK FACTORS

Patient factors

  • Male
  • Delirium
  • Light sedation (note that most studies of daily interuppted sedation did not show increased rates of unplanned extubation)
  • Difficulty securing tube (e.g. facial swelling, facial burns)
  • previous unplanned extubation

Staff factors

  • Junior staff
  • Nurse-to-patient ratio
  • Inadequately secured endotracheal tube and/or checks

Use of restraints and midazolam use are controversial risk factors for self-extubation, it may be that these are confounded by delirium

COMPLICATIONS

  • effects of extubation with ETT cuff up
    • hemodynamic effects: hypotension, arrhythmias
    • laryngeal injury, bleeding or oedema
  • airway obstruction
  • acute pulmonary oedema due to loss of CPAP/PEEP in a patient with left ventricular failure
  • respiratory failure
  • aspiration
  • reintubation and associated sequelae (e.g. prolonged stay, complications of mechanical ventilation, etc)

MANAGEMENT

  • attend to potential life-threats using an ABC approach
  • many patients (>50%) do not require reintubation if oxygenation and ventilation remains adequate (consider oxygen via NP or mask, high flow nasal prongs or NIV)
  • check previous airway grade, obtain difficult airway trolley and call for assistance if likely difficult grade of intubation
  • if stridor present, may need a smaller ETT than previously used due to laryngeal trauma/ oedema
  • ensure the incident is documented and entered into a risk monitoring system; need to address cause of self-extubation

PREVENTION

  • ensure endotracheal tube is well secured
  • regular checks on endotracheal tube position and security
  • identify patients appropriate for extubation as early as possible
  • ensure appropriate analgesia, sedation and delirium management
  • safe procedures should be established for performing oral care, renewing tube tapes and changing patient position on bed
  • additional staff should be provided during high risk procedures e.g. transport
  • use of restraints is controversial

References and Links

Journal articles

  • Kiekkas P, Aretha D, Panteli E, Baltopoulos GI, Filos KS. Unplanned extubation in critically ill adults: clinical review. Nurs Crit Care. 2013 May;18(3):123-34. PMID: 23577947.
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Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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