Risk factors for unplanned extubation in ventilated neonates in South Korea

Prevalence of unplanned extubation in a tertiary care neonatal intensive care unit

Orotracheal intubation and mechanical ventilation (MV) have become routine practices in intensive care units. Unplanned extubation (UE) is one of the most important complications, particularly in premature infants and critically ill newborns. The objective of this study was to determine the prevalence of UE in a tertiary care neonatal intensive care unit (NICU). In this analytical cross-sectional retrospective study, all data, including perinatal data, indications for ventilatory support, days of MV at the time of UE, work shift, month of the event, reintubation, and postextubation complications, were obtained from the manual review of clinical charts. In total, 151 neonates, who received invasive MV, were included in this study. The prevalence of UE was 2.0/100 days of ventilation. The most affected were premature infants, with a gestational age of ≤ 32 weeks (54.7%) and a birth weight of ≤ 1500 g. The main cause for UE was deficient fixation of the endotracheal tube (ETT) (27.7%). Most UE events occurred during night shifts (48.1%). Reintubation was required in 83.3% of newborns. Immediate complications developed in 96.3% of the UE events, including desaturation (57.7%) and bradycardia (36.5%). The prevalence of UE was high, particularly in premature infants, with a high rate of reintubation and immediate complications. Standardized protocols for ETT care must be implemented to reduce these events.

Respiratory outcomes and survival after unplanned extubation in the NICU: a prospective cohort study from the SEPREVEN trial

OBJECTIVE

To compare reintubation rates after planned extubation and unplanned extubation (UE) in patients in neonatal intensive care units (NICUs), to analyse risk factors for reintubation after UE and to compare outcomes in patients with and without UE.

DESIGN

Prospective, observational study nested in a randomised controlled trial (SEPREVEN/Study on Epidemiology and PRevention of adverse EVEnts in Neonates). Outcomes were expected to be independent of the intervention tested.

SETTING

12 NICUs in France with a 20-month follow-up, starting November 2015.

PATIENTS

n=2280 patients with a NICU stay >2 days, postmenstrual age ≤42 weeks on admission.

INTERVENTIONS/EXPOSURE

Characteristics of UE (context, timing, sedative administration in the preceding 6 hours, weaning from ventilation at time of UE) and patients.

MAIN OUTCOME MEASURES

Healthcare professional-reported UE rates, reintubation/timing after extubation, duration of mechanical ventilation, mortality and bronchopulmonary dysplasia (BPD).

RESULTS

There were 162 episodes of UE (139 patients, median gestational age (IQR) 27.3 (25.6-31.7) weeks). Cumulative reintubation rates within 24 hours and 7 days of UE were, respectively, 50.0% and 57.5%, compared with 5.5% and 12.3% after a planned extubation. Independent risk factors for reintubation within 7 days included absence of weaning at the time of UE (HR, 95% CI) and sedatives in the preceding 6 hours (HR 1.93, 95% CI 1.04 to 3.60). Mortality at discharge did not differ between patients with planned extubation or UE. UE was associated with a higher risk of BPD.

CONCLUSION

In the SEPREVEN trial, reintubation followed UE in 58% of the cases, compared with 12% after planned extubation.

TRIAL REGISTRATION NUMBER

NCT02598609.

Development and testing of a questionnaire assessing knowledge, attitudes, and practices to prevent unplanned oral extubation

BACKGROUND

The prevention of unplanned endotracheal extubation (UEE) is significant for the critical care of intensive care unit (ICU) patients.

AIM

To develop a questionnaire to assess the knowledge, attitude, and practice (KAP) of the nurses regarding of the prevention of UEE in ICU patients with transoral endotracheal intubation (TEI) and to test the validity and reliability of the questionnaire.

STUDY DESIGN

Items relevant to KAP were prepared following a literature review, and then screened using a Delphi expert consultation, pre-test, and factor analysis. The nursing staffs in four tertiary hospitals in Qinghai, Jiangsu, Gansu, and Shandong provinces were surveyed to test the reliability and validity of the questionnaire.

RESULTS

The questionnaire contained 76 items, including 10, 37, and 29 in the dimensions of knowledge, attitude, and practice, respectively. The scale-level content validity index (S-CVI) of the questionnaire was 0.96. The results of exploratory factor analysis (EFA) showed that the Kaiser-Meyer-Olkin value was 0.956, indicating that the sample was adequate and suitable for factor analysis. The result of the Bartlett spherical test was significant (p < .001), indicating that the questionnaire was suitable for further EFA. A total of six common factors were extracted by EFA with a cumulative variance interpretation rate of 85.52%, indicating that the questionnaire had good structural validity. The Cronbach's alpha was 0.981 for the whole questionnaire; and was 0.966, 0.996, and 0.981 for the dimensions of knowledge, attitude, and practice, respectively. The test-retest reliability for the questionnaire was 0.843.

CONCLUSIONS

The developed questionnaire has good reliability and validity and can be used as a scientific tool for the nursing leaders to prevent UEE in ICU patients with TEI.

RELEVANCE TO CLINICAL PRACTICE

The instrument provides a theoretical reference for establishing preventive strategies and management programs in clinical practice.

Predictive value of the unplanned extubation risk assessment scale in hospitalized patients with tubes

BACKGROUND

Critical patients often had various types of tubes, unplanned extubation of any kind of tube may cause serious injury to the patient, but previous reports mainly focused on endotracheal intubation. The limitations or incorrect use of the unplanned extubation risk assessment tool may lead to improper identification of patients at a high risk of unplanned extubation and cause delay or non-implementation of unplanned extubation prevention interventions. To effectively identify and manage the risk of unplanned extubation, a comprehensive and universal unplanned extubation risk assessment tool is needed.

AIM

To assess the predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale in inpatients.

METHODS

This was a retrospective validation study. In this study, medical records were extracted between October 2020 and September 2021 from a tertiary comprehensive hospital in southwest China. For patients with tubes during hospitalization, the following information was extracted from the hospital information system: age, sex, admission mode, education, marital status, number of tubes, discharge mode, unplanned extubation occurrence, and the Huaxi Unplanned Extubation Risk Assessment Scale (HUERAS) score. Only inpatients were included, and those with indwelling needles were excluded. The best cut-off value and the area under the curve (AUC) of the Huaxi Unplanned Extubation Risk Assessment Scale were been identified.

RESULTS

A total of 76033 inpatients with indwelling tubes were included in this study, and 26 unplanned extubations occurred. The patients’ HUERAS scores were between 11 and 30, with an average score of 17.25 ± 3.73. The scores of patients with or without unplanned extubation were 22.85 ± 3.28 and 17.25 ± 3.73, respectively (P < 0.001). The results of the correlation analysis showed that the correlation coefficients between each characteristic and the total score ranged from 0.183 to 0.843. The best cut-off value was 21, and there were 14135 patients with a high risk of unplanned extubation, accounting for 18.59%. The Cronbach’s α, sensitivity, specificity, positive predictive value, and negative predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale were 0.815, 84.62%, 81.43%, 0.16%, and 99.99%, respectively. The AUC of HUERAS was 0.851 (95%CI: 0.783-0.919, P < 0.001).

CONCLUSION

The HUERAS has good reliability and predictive validity. It can effectively identify inpatients at a high risk of unplanned extubation and help clinical nurses carry out risk screening and management.