Unplanned Extubation: Discussion
Unplanned extubation—self-extubation or accidental extubation—occurs with surprising frequency in mechanically ventilated patients. In our study, the incidence of unplanned extubation was 7 percent, similar to the 8.5 percent to 16 percent reported in other studies. Furthermore, unplanned extubation is difficult to prevent, as evidenced by the fact that 65 percent of our patients had been sedated within 4 h of extubation, and that at least 91 percent were restrained. Stauffer and coworkers observed that some patients extubated themselves repeatedly despite arm restraints and careful attention by the was respiratory failure associated with toxic ingestion (6 percent); furthermore, the primary reason for prolonged mechanical ventilation in this patient was nosocomial sepsis. Within the RI group, the most common cause of respiratory failure was pneumonia, cited as the primary diagnosis in 12 of the 18 patients (67 percent). All three patients with Pneumocystis carinii pneumonia required reintubation, as did eight of the nine patients with bacterial or atypical pneumonia. Allergy medications so However, the presence of pneumonia was not a predictor of reintubation (p=0.155).
Both patients with adult respiratory distress syndrome (ARDS) needed to be reintubated. Obstructive lung disease was present in five cases of self-extubation, and four patients required reintubation (80 percent). Overall, pulmonary disease was present in 15 of the 18 events (83 percent) in the RI group and was strongly associated with the need for reintubation (p=0.017). Of the respiratory and ventilatory parameters studied, only FI02 and We differed between the two groups (Table 2). The mean pre-extubation FI02 of the RI group (0.50) was significantly higher than that of the NRI group (0.35, p=0.021). Furthermore, all of the patients receiving an FI02 >0.40 were reintubated, while only 9 of the 14 patients receiving an FI02 <0.40 were reintubated (Fig 1). The We was also much higher in the RI group (9.7 L/min) than nursing staff. In another study, the majority of patients were either sedated or restrained at the time of extubation, and many patients had been recognized as being agitated prior to extubation;2 the same study was unable to identify any risk factors for self-extubation. Medina and coworkers recently showed that unplanned extubation was less frequent among patients with chest and arm restraints in place than among patients with arm restraints alone; however, a statistically significant difference was not shown. Although paralysis with neuromuscular blocking agents will prevent self-extubation, it is associated with other complications.