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Macpherson D, Hutchinson A, Bloomer MJ. Factors that influence critical care nurses' management of sedation for ventilated patients in critical care: A qualitative study. Intensive Crit Care Nurs 2024; 83:103685. [PMID: 38493573 DOI: 10.1016/j.iccn.2024.103685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 03/05/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce. AIM To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making. DESIGN Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis. SETTING AND PARTICIPANTS This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate. FINDINGS Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation. CONCLUSION Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns. IMPLICATIONS FOR CLINICAL PRACTICE Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making.
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Affiliation(s)
- Danielle Macpherson
- Intensive Care Unit, Epworth HealthCare Richmond, Victoria, Australia; School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
| | - Anastasia Hutchinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research in the Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia; Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Richmond, Victoria, Australia
| | - Melissa J Bloomer
- School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia; Intensive Care Unit, Princess Alexandra Hospital, Queensland Health, Woolloongabba, Queensland, Australia.
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Anis A, Patel R, Tanios MA. Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches. J Intensive Care Med 2024; 39:507-513. [PMID: 37670719 DOI: 10.1177/08850666231199055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE.
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Affiliation(s)
- Antonious Anis
- Internal Medicine Residency Program, St. Mary Medical Center, Long Beach, CA, USA
- Critical Care Medicine Fellowship, University of Nevada Las Vegas, Las Vegas, NV, USA
| | - Ravi Patel
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, CA, USA
| | - Maged A Tanios
- Division of Pulmonary Diseases and Critical Care Medicine, University of California, Irvine, CA, USA
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Wang M, Pan S, Sun L, Sun X, Ma Q. Development and testing of a questionnaire assessing knowledge, attitudes, and practices to prevent unplanned oral extubation. Nurs Crit Care 2024; 29:366-384. [PMID: 37592820 DOI: 10.1111/nicc.12953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/13/2023] [Accepted: 07/05/2023] [Indexed: 08/19/2023]
Abstract
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.
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Affiliation(s)
- Meizhong Wang
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Shiqin Pan
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Lijuan Sun
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Xiaolin Sun
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
| | - Qin Ma
- Intensive Care of Unit, Qinghai Provincial People's Hospital, Xining, China
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Luo Y, Luo S, Luo L, Ou M, Tang M. Effect of hydrocolloid dressing on pressure ulcer in patients with non-invasive positive pressure ventilation: A meta-analysis. Int Wound J 2023; 21:e14442. [PMID: 37857589 PMCID: PMC10828119 DOI: 10.1111/iwj.14442] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 09/25/2023] [Accepted: 10/02/2023] [Indexed: 10/21/2023] Open
Abstract
This study systematically evaluated the effect of hydrocolloid dressings on facial pressure ulcers in patients receiving non-invasive positive pressure ventilation (NIPPV). The Embase, PubMed, Cochrane Library, CNKI, VIP, Chinese Biomedical Literature Database and Wanfang databases were searched for randomised controlled trials on the use of hydrocolloid dressings in patients receiving NIPPV published from the inception of each database to August 2023. The literature was independently screened, data were extracted by two authors based on the inclusion and exclusion criteria, and the quality of the included literature was assessed. The meta-analysis was performed using Stata 17.0. Thirteen studies including 1248 patients were included, with 639 patients in the intervention group and 609 patients in the control group. Meta-analysis showed that the hydrocolloid dressing significantly reduced the incidence of facial pressure ulcers in patients with NIPPV (odds ratio = 0.16, 95% confidence intervals: 0.11-0.24, p < 0.001). Hydrocolloid dressings are effective in reducing the incidence of facial pressure ulcers in patients receiving NIPPV. However, because of the small number of included studies, this conclusion needs to be confirmed with larger samples and high-quality clinical studies.
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Affiliation(s)
- Yu‐Lan Luo
- Department of Critial Care MedicineWest China Hospital, Sichuan University/West China School of Nursing, Sichuan UniversityChengduSichuanChina
| | - Shi‐Feng Luo
- Department of Critial Care MedicineWest China Hospital, Sichuan University/West China School of Nursing, Sichuan UniversityChengduSichuanChina
| | - Lin Luo
- Department of Critial Care MedicineWest China Hospital, Sichuan University/West China School of Nursing, Sichuan UniversityChengduSichuanChina
| | - Min Ou
- Department of Critial Care MedicineWest China Hospital, Sichuan University/West China School of Nursing, Sichuan UniversityChengduSichuanChina
| | - Meng‐Lin Tang
- Department of Cardiovascular SurgeryWest China Hospital, Sichuan University/West China School of Nursing, Sichuan UniversityChengduSichuanChina
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Lin YH, Chang WP. Characteristics and risk factors of facial pressure injuries in acute inpatients using noninvasive positive pressure ventilation: A retrospective case control study. Intensive Crit Care Nurs 2023; 78:103453. [PMID: 37172467 DOI: 10.1016/j.iccn.2023.103453] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To explore the characteristics and risk factors of facial pressure injuries in patients using noninvasive positive pressure ventilation. SETTING AND SAMPLE Patients who developed facial pressure injuries due to non-invasive positive pressure ventilation at a teaching hospital in Taiwan from January 2016 to December 2021 were selected, resulting in a total of 108 patients in our case group. A control group was formed by matching each case by age and gender to three acute inpatients who had used non-invasive ventilation but had not developed facial pressure injuries, resulting in 324 patients in the control group. RESEARCH METHODOLOGY This study was a retrospective case-control study. The characteristics of the patients who developed pressure injuries at different stages in the case group were compared, and the risk factors of non-invasive ventilation-related facial pressure injuries were then determined. RESULTS Higher duration of non-invasive ventilation usage, higher length of hospital stay, lower Braden scale score, and lower albumin levels in the former group. The results of multivariate analysis from binary logistic regression involving the duration of non-invasive ventilation usage demonstrated that the patients who used this device for 4-9 days and 16 days were at greater risk of facial pressure injuries than those who used it for 3 days; in terms of the Braden scale score, higher Braden scale scores were correlated with a higher risk of facial pressure injuries. In addition, albumin levels lower than the normal range were correlated with a higher risk of facial pressure injuries. CONCLUSION Patients with pressure injuries at higher stages had a higher duration of non-invasive ventilation usage, higher length of hospital stay, lower Braden scale scores, and lower albumin levels. Thus, a longer duration of non-invasive ventilation use, lower Braden scale scores, and lower albumin levels were also risk factors for non-invasive ventilation-related facial pressure injuries. IMPLICATIONS FOR CLINICAL PRACTICE Our results serve as a useful reference for hospitals, both in creating training programs for their medical teams to prevent and treat facial pressure injuries and in drafting guidelines for assessing risk in order to prevent facial pressure injuries caused by non-invasive ventilation. The duration of device usage, Braden scale scores, and albumin levels in particular should be seriously monitored to reduce the occurrence of facial pressure injuries in acute inpatients treated with non-invasive ventilation.
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Affiliation(s)
- Yu-Huei Lin
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Research Center in Nursing Clinical Practice, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Pei Chang
- Department of Nursing, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.
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Okano DR, Perez Toledo JA, Mitchell SA, Cartwright JF, Moore C, Boyer TJ. Intraoperative Accidental Extubation during Thyroidectomy in a Known Difficult-Airway Patient: An Adult Simulation Case for Anesthesiology Residents. Healthcare (Basel) 2022; 10:healthcare10102013. [PMID: 36292458 PMCID: PMC9601688 DOI: 10.3390/healthcare10102013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 11/04/2022] Open
Abstract
Intraoperative accidental extubation on a known difficult-airway patient requires prompt attention. A good understanding of the steps to re-establish the airway is critical, especially when the patient is known to have a difficult airway documented or discovered on induction or acquires a difficult airway secondary to intraoperative events. The situation becomes even more complicated if the case has been handed off to another anesthesiologist, where specific and detailed information may not have been conveyed. This simulation was designed to train first-year clinical anesthesia residents. It was a 50 min encounter that focused on the management of complete loss of an airway during a thyroidectomy on a known difficult-airway patient. The endotracheal tube dislodgement was simulated by deliberate tube manipulation through the cervical access window of the mannequin. Learners received a formative assessment of their performance during the debrief, and most of the residents met the educational objectives. Learners were asked to complete a survey of their experience, and the feedback was positive and constructive. The response rate was 68% (17/25). Our simulation program helped anesthesiology residents develop intraoperative emergency airway management skills in a safe environment, as well as foster communication skills among anesthesiologists and the surgery team.
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Affiliation(s)
- David R. Okano
- Department of Anesthesia, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
- Correspondence:
| | | | - Sally A. Mitchell
- Department of Anesthesia, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Johnny F. Cartwright
- Department of Anesthesia, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Christopher Moore
- Department of Anesthesia, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
| | - Tanna J. Boyer
- Department of Anesthesia, School of Medicine, Indiana University, Indianapolis, IN 46202, USA
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Ho CL, Ju TR, Lee CC, Lin HT, Wang AL, Chen RJ, Lin YC. The Early Dynamic Change in Cardiac Enzymes and Renal Function Is Associated with Mortality in Patients with Fulminant Myocarditis on Extracorporeal Membrane Oxygenation: Analysis of a Single Center's Experience. Healthcare (Basel) 2022; 10:1063. [PMID: 35742115 PMCID: PMC9222735 DOI: 10.3390/healthcare10061063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/04/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
(1) Background: Fulminant myocarditis (FM) could result in hemodynamic derangement and fatal arrhythmia. Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is used to maintain organ perfusion in FM patients complicating cardiogenic shock. The present study aims to assess the static and dynamic factors in association with mortality in FM patients on V-A ECMO (2) Methods: Twenty-eight patients were enrolled between 2013 to 2019 for analysis (3) Results: In-hospital survival rate was 78.5%. There was no statistical difference in demographics and baseline laboratory data between survivors and non-survivors. However, within 24 h after ECMO support, CK-MB increased by 96.8% among non-survivors, but decreased by 23.7% among survivors (p = 0.022). Troponin I increased by 378% among non-survivors and 1.7% among survivors (p = 0.032). Serum creatinine increased by 108% among non-survivors, but decreased by 8.5% among survivors (p = 0.005). The receiver operating characteristic curve suggested an increase in serum creatinine by 68% within 24 h after ECMO support was associated with increased mortality with an area under the curve of 0.91. (4) Conclusions: V-A ECMO is an excellent tool to support FM patients with cardiogenic shock. The early dynamic change of renal function and cardiac enzymes may be useful for outcome assessment.
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Affiliation(s)
- Ching-Lin Ho
- Department of Surgery, Division of Cardiovascular Surgery, China Medical University Hospital, Taichung City 406040, Taiwan;
| | - Teressa Reanne Ju
- Department of Internal Medicine, New York Presbyterian Queens, New York, NY 11355, USA;
| | - Chi Chan Lee
- Department of Critical Care, Guam Regional Medical City, Tamuning, GU 96929, USA;
| | - Hsin-Ti Lin
- College of Medicine, China Medical University, Taichung City 406040, Taiwan; (H.-T.L.); (A.-L.W.)
| | - Alexander-Lee Wang
- College of Medicine, China Medical University, Taichung City 406040, Taiwan; (H.-T.L.); (A.-L.W.)
| | - Robert Jeenchen Chen
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, USA;
| | - You-Cian Lin
- Department of Surgery, Division of Cardiovascular Surgery, China Medical University Hospital, Taichung City 406040, Taiwan;
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Li P, Sun Z, Xu J. Unplanned extubation among critically ill adults: A systematic review and meta-analysis. Intensive Crit Care Nurs 2022; 70:103219. [DOI: 10.1016/j.iccn.2022.103219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 01/10/2023]
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Ju TR, Wang E, Castaneda C, Rathod A, Abe O. Superficial placement of endotracheal tubes associated with unplanned extubation: A case-control study. J Crit Care 2021; 67:39-43. [PMID: 34649093 DOI: 10.1016/j.jcrc.2021.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/01/2021] [Accepted: 09/24/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Unplanned extubations (UEs) refer to the inadvertent removal of endotracheal tubes (ETTs). Superficially placed ETTs anecdotally increases the risk of UEs. This study aims to assess the impact of ETT position as well as other factors that could be associated with risk of UEs. METHOD A retrospective case-control study was conducted at NewYork-Presbyterian Queens Hospital from January 2017 to February 2020. All adults admitted to intensive care units (ICUs) who received mechanical ventilation (MV) through ETTs were screened to identify UEs. For each case with UE, two controls with planned extubation were identified. A multivariate logistic regression was conducted to identify risk factors associated with UEs. RESULTS 1100 patients received MV through ETTs during the time period. The incidence of UE was 4.9%. 53 patients with UEs and 106 patients with planned extubation were included for statistical analysis. Overall, patients with UE had higher in-hospital mortality rates (26.4% versus 11.3%, P = 0.02) and reintubation rates (28.3% versus 6.6%, P < 0.001). Within the UE group, patients who required reintubation had significantly higher in-hospital mortality rates than those who did not require reintubation (53.3% versus 15.8%, P = 0.005). Multivariate logistic regression showed higher APACHE II scores (Odds ratios (OR) 1.07; 95% Confidence interval (CI), 1 to 1.13), distance of ETT tips to carina ≥6 cm (OR 6.41; 95% CI, 1.1 to 37.3), physical restraint use (OR 2.98; 95% CI, 1.28 to 6.95) and continuous infusions of sedatives and/or analgesics (OR 10.72, 95% CI, 4.19 to 27.43) were associated with UE. CONCLUSION UE and the need for reintubation is associated with worse outcomes. Distance of ETT tips to carina ≥6 cm may be associated with higher risks of UE. Further prospective studies are needed to establish the optimal position of ETT to prevent UE.
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Affiliation(s)
- Teressa Reanne Ju
- Department of Medicine, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA.
| | - Emily Wang
- Department of Medicine, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA
| | - Christian Castaneda
- Department of Medicine, Division of Pulmonary and Critical Care, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA
| | - Anisha Rathod
- Department of Respiratory Therapy, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA
| | - Olumayowa Abe
- Department of Medicine, Division of Pulmonary and Critical Care, NewYork-Presbyterian Queens Hospital, Flushing, NY, USA; Weill Cornell Medical College, Cornell University, NY, New York, United States of America
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Kerber K, Zangmeister J, McNett M. Relationship Between Delirium and Ventilatory Outcomes in the Medical Intensive Care Unit. Crit Care Nurse 2021; 40:24-31. [PMID: 32236430 DOI: 10.4037/ccn2020697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Delirium is a common neuropsychiatric diagnosis in intensive care units and often leads to extended hospital stays and an increased rate of complications. Delirium can be classified as hypoactive, hyperactive, or mixed. Hyperactive delirium is often accompanied by agitation, which is a predictive factor for unplanned extubation. Hypoactive delirium does not include outward agitation; its incidence and relationship to ventilatory outcomes, specifically unplanned extubation and duration of mechanical ventilation, are relatively unexplored. OBJECTIVE To determine the occurrence rate of each delirium type in the first 7 days after intensive care unit admission and explore the relationship between delirium type and ventilatory outcomes. METHODS This was a retrospective cohort study that enrolled adult patients consecutively admitted to a medical intensive care unit over 12 months. Data were abstracted on patient demographic variables, daily clinical variables (morning and evening delirium, coma, and sedation scores), and outcome variables (unplanned extubation, length of stay, and duration of mechanical ventilation). RESULTS We enrolled 171 patients in the study. Hypoactive delirium occurred in up to 44% of patients. Of 25 instances of unplanned extubation, up to 74% of patients had hypoactive delirium. Delirium was not a predictor of unplanned extubation; smoking history, chronic obstructive pulmonary disease, and failed breathing trials best predicted unplanned extubation (odds ratios = 3.2, 5.2, and 12.6, respectively; P < .05). CONCLUSIONS Hypoactive delirium is common among intensive care unit patients and may precede unplanned extubation. Patient history and comorbidities remain the strongest predictors of unplanned extubation.
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Affiliation(s)
- Kathleen Kerber
- Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and the medical step-down unit, MetroHealth Medical Center, Cleveland, Ohio. Jessica Zangmeister is a clinical nurse in the medical intensive care unit, MetroHealth Medical Center. Molly McNett is Professor of Clinical Nursing and Assistant Director of Implementation Science, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Jessica Zangmeister
- Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and the medical step-down unit, MetroHealth Medical Center, Cleveland, Ohio. Jessica Zangmeister is a clinical nurse in the medical intensive care unit, MetroHealth Medical Center. Molly McNett is Professor of Clinical Nursing and Assistant Director of Implementation Science, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Molly McNett
- Kathleen Kerber is a clinical nurse specialist in the medical intensive care unit and the medical step-down unit, MetroHealth Medical Center, Cleveland, Ohio. Jessica Zangmeister is a clinical nurse in the medical intensive care unit, MetroHealth Medical Center. Molly McNett is Professor of Clinical Nursing and Assistant Director of Implementation Science, College of Nursing, The Ohio State University, Columbus, Ohio
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Ullah R, Doerfer K, Khampang P, Fathi F, Hong W, Kerschner JE, Yu B. Real-Time Optical Monitoring of Endotracheal Tube Displacement. BIOSENSORS 2020; 10:bios10110174. [PMID: 33198131 PMCID: PMC7696368 DOI: 10.3390/bios10110174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/07/2020] [Accepted: 11/10/2020] [Indexed: 11/16/2022]
Abstract
Proper ventilation of a patient with an endotracheal tube (ETT) requires proper placement of the ETT. We present a sensitive, noninvasive, operator-free, and cost-effective optical sensor, called Opt-ETT, for the real-time assessment of ETT placement and alerting of the clinical care team should the ETT become displaced. The Opt-ETT uses a side-firing optical fiber, a near-infrared light-emitting diode, two photodetectors with an integrated amplifier, an Arduino board, and a computer loaded with a custom LabVIEW program to monitor the position of the endotracheal tube inside the windpipe. The Opt-ETT generates a visual and audible warning if the tube moves over a distance set by the operator. Displacement prediction is made using a second-order polynomial fit to the voltages measured from each detector. The system is tested on ex vivo porcine tissues, and the accuracy is determined to be better than 1.0 mm. In vivo experiments with a pig are conducted to test the performance and usability of the system.
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Affiliation(s)
- Ramzan Ullah
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI 53233, USA; (R.U.); (F.F.)
| | - Karl Doerfer
- Departments of Microbiology and Otolaryngology, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (K.D.); (P.K.); (W.H.); (J.E.K.)
| | - Pawjai Khampang
- Departments of Microbiology and Otolaryngology, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (K.D.); (P.K.); (W.H.); (J.E.K.)
| | - Faraneh Fathi
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI 53233, USA; (R.U.); (F.F.)
| | - Wenzhou Hong
- Departments of Microbiology and Otolaryngology, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (K.D.); (P.K.); (W.H.); (J.E.K.)
| | - Joseph E. Kerschner
- Departments of Microbiology and Otolaryngology, Medical College of Wisconsin, Milwaukee, WI 53226, USA; (K.D.); (P.K.); (W.H.); (J.E.K.)
| | - Bing Yu
- Department of Biomedical Engineering, Marquette University and Medical College of Wisconsin, Milwaukee, WI 53233, USA; (R.U.); (F.F.)
- Correspondence:
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Berkow L, Kanowitz A. COVID-19 Putting Patients at Risk of Unplanned Extubation and Airway Providers at Increased Risk of Contamination. Anesth Analg 2020; 131:e41-e43. [PMID: 32304463 PMCID: PMC7179054 DOI: 10.1213/ane.0000000000004890] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lauren Berkow
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, Airway Safety Movement Highlands Ranch, Colorado
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13
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Cheng AC, Liao KM, Ho CH, Lai CC, Chao CM, Chiu CC, Chiang SR, Cheng KC, Chen CM. The prognosis in extremely elderly patients receiving orotracheal intubation and mechanical ventilation after planned extubation. Medicine (Baltimore) 2020; 99:e21970. [PMID: 32957315 PMCID: PMC7505301 DOI: 10.1097/md.0000000000021970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The main objective of this study was to evaluate the outcomes of extremely elderly patients receiving orotracheal intubation and mechanical ventilation after planned extubation. This retrospective cohort study included extremely elderly patients (>90 years) who received mechanical ventilation and passed planned extubation. We reviewed all intensive care unit patients in a medical center between January 1, 2010, and December 31, 2017. There were 19,518 patients (aged between 20 and 105 years) during the study period. After application of the exclusion criteria, there were 213 patients who underwent planned extubation: 166 patients survived, and 47 patients died. Compared with the mortality group, the survival group had lower Acute Physiology and Chronic Health Evaluation II scores and higher Glasgow Coma Scale (GCS) scores, with scores of 19.7 ± 6.5 (mean ± standard deviation) vs 22.2 ± 6.0 (P = .015) and 9.5 ± 3.5 vs 8.0 ± 3.0 (P = .007), respectively. The laboratory data revealed no significant difference between the survival and mortality groups except for blood urea nitrogen (BUN) and hemoglobin. After multivariate logistic regression analysis, a lower GCS, a higher BUN level, weaning beginning 3 days after intubation and reintubation during hospitalization were associated with poor prognosis. In this cohort of extremely elderly patients undergoing planned extubation, a lower GCS, a higher BUN level, weaning beginning 3 days after intubation and reintubation during hospitalization were associated with mortality.
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Affiliation(s)
- Ai-Chin Cheng
- Division of Respiratory Therapy, Department of Internal Medicine, Chi Mei Medical Center
- Department of Health Care Administration, Chang Jung Christian University, Tainan
| | - Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan
- Department of Hospital and Health Care Administration, Chia-Nan University of Pharmacy and Science
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch
| | | | - Chong-Chi Chiu
- Department of General Surgery, E-Da Cancer Hospital, I-Shou University, Kaohsiung
| | | | | | - Chin-Ming Chen
- Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan
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Lin PH, Chen CF, Chiu HW, Tai HP, Lee DL, Lai RS. Outcomes of unplanned extubation in ordinary ward are similar to those in intensive care unit: A STROBE-compliant case-control study. Medicine (Baltimore) 2019; 98:e14841. [PMID: 30882675 PMCID: PMC6426589 DOI: 10.1097/md.0000000000014841] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Unplanned extubation (UE) may cause considerable adverse effects in patients receiving mechanical ventilation (MV). Previous literature showed inconsistent prognosis in patients with UE. This study aimed to evaluate the clinical implications and outcomes of UE.The intubated adult patients with MV support in our hospital were enrolled, and they were divided into the UE and non-UE groups. Demographic data, admission unit, MV duration, overall weaning rate, and mortality rates were compared. The outcomes of UE in ordinary ward and intensive care unit (ICU) were also assessed.Totally 9245 intubated adult patients were included. UE occurred in 303 (3.5%) patients, and the UE events were 0.27 times/100 MV days. Old age, nonoperation related MV cause, and admission out of the ICU were significant factors associated with UE events. UE patients showed a trend of better overall weaning rate (71.9% vs 66.7%, P = .054) than non-UE. However, the in-hospital mortality rate (25.7% vs 24.8%, P = .713) were similar between the UE and non-UE patients. The reintubation rate of UE patients was 44.1% (142/322). Successful UEs were associated with patients in weaning process (52.8% vs 38.7%, P = .012), and patients received non-invasive positive pressure ventilation (NIPPV) support after UE (19.4% vs 3.5%, P < .001). Patients with successful UE had significantly shorter MV days, higher overall weaning rate, and lower mortality than those with unsuccessful UE. Outcomes of UE in ordinary ward and in ICU had similar MV duration, reintubation rate, overall weaning rate, and in-hospital mortality rate.The overall weaning rate and in-hospital mortality rates of the UE and non-UE patients were similar. UE occurred in ordinary ward had similar outcomes to those in ICU. Patients receiving MV should be assessed daily for weaning indications to reduce delayed extubation, and therefore, may decrease UE occurrence. Once the UE happened, NIPPV support may reduce the reintubation rate.
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Affiliation(s)
| | - Chiu-Fan Chen
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Department of Internal Medicine, Taipei Veterans General Hospital, Taitung Branch, Taitung
| | - Hsin-Wei Chiu
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Hsueh-Ping Tai
- Sub-acute Respiratory care ward, Department of Nursing, Kaohsiung Veterans General Hospital, Kaohsiung
| | - David Lin Lee
- Division of Respiratory Therapy
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ruay-Sheng Lai
- Division of Respiratory Therapy
- Division of Chest Medicine, Kaohsiung Veterans General Hospital, Kaohsiung
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
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Danielis M, Chiaruttini S, Palese A. Unplanned extubations in an intensive care unit: Findings from a critical incident technique. Intensive Crit Care Nurs 2018; 47:69-77. [PMID: 29776707 DOI: 10.1016/j.iccn.2018.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/16/2018] [Accepted: 04/30/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Patients on mechanical ventilation are at risk of experiencing a potentially life-threatening unplanned extubation in the intensive care unit, which can lead to arrhythmias, bronchial aspiration, difficulty in reintubation or even sudden cardiac arrest. Although incidence and outcomes of the phenomenon have been documented in several quantitative studies, no studies have investigated the antecedents as experienced by critical care nurses. OBJECTIVES To gain a greater understanding of the antecedents of unplanned extubations. METHODS A qualitative study design involving the critical-incident technique. A total of 10 registered nurses who reported one or more episodes of unplanned extubations were involved in an in-depth interview. FINDINGS According to the nurses' experience, episodes of unplanned extubations are determined by predisposing, precipitating and mediating factors. The predisposing factors have been recognised in the (a) weaning programme (expected/unexpected decreased sedation) and in the (b) patient factors (increased needs due to discomfort, restlessness and desire to communicate). The precipitating factors have been divided into (a) organisational (failures in multi-professional communication), (b) environmental (excessive environmental chaos and barriers preventing direct surveillance) and (c) nursing care factors (ensuring privacy by creating barriers, avoiding disturbing other patients and poor nurse-to-patient ratio). Among the mediating factors, which are affected by the precipitating factors, decreased surveillance and mechanical restraints' use have been identified. CONCLUSION Identifying risk factors of unplanned extubation, specifically those that are modifiable, such as increasing interprofessional communication, reducing excessive environment chaos, implementing strategies aimed at overcoming barriers threatening direct surveillance and ensuring appropriate nurse-to-patient ratio, can prevent the occurrence of these events.
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Affiliation(s)
- Matteo Danielis
- Department of Anaesthesia and Intensive Care - Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Simona Chiaruttini
- School of Nursing, Department of Medical Sciences, Udine University, Italy
| | - Alvisa Palese
- School of Nursing, Department of Medical Sciences, Udine University, Italy.
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Lucchini A, Bambi S, Galazzi A, Elli S, Negrini C, Vaccino S, Triantafillidis S, Biancardi A, Cozzari M, Fumagalli R, Foti G. Unplanned extubations in general intensive care unit: A nine-year retrospective analysis. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:25-31. [PMID: 30539936 PMCID: PMC6502139 DOI: 10.23750/abm.v89i7-s.7815] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 11/23/2022]
Abstract
Background and aim: Unplanned extubation (UE) in Intensive Care Units (ICU) is an indicator of quality and safety of care. UEs are classified in: accidental extubations, if involuntarily caused during nursing care or medical procedures; self-extubation, if determined by the patient him/herself. In scientific literature, the cumulative incidence of UEs varies from 0.3% to 35.8%. The aim of this study is to explore the incidence of UEs in an Italian university general ICU adopting a well-established protocol of tracheal tube nursing management and fixation. Methods: retrospective observational study. We enrolled all patients undergone to invasive mechanical ventilation from 1st January 2008 to 31st December 2016. Results: in the studied period 3422 patients underwent to endotracheal intubation. The UEs were 35: 33 self extubations (94%) and 2 accidental extubations (6%). The incidence of UEs calculated on 1497 patients intubated for more than 24 hours was 2.34%. Instead, it was 1.02%, if we consider the whole number of intubated patients. Only in 9 (26%) cases out of 35 UEs the patient was re-intubated. No deaths consequent to UE were recorded. Conclusions: The incidence of UEs in this study showed rates according to the minimal values reported in scientific literature. A standardized program of endotracheal tube management (based on an effective and comfortable fixing system) seems to be a safe and a valid foundation in order to maintain the UE episodes at minimum rates.
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Affiliation(s)
- Alberto Lucchini
- ASST Monza, Ospedale San Gerardo - università degli Studi di Milano-Bicocca.
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Hsieh MH, Hsieh MJ, Chen CM, Hsieh CC, Chao CM, Lai CC. Comparison of machine learning models for the prediction of mortality of patients with unplanned extubation in intensive care units. Sci Rep 2018; 8:17116. [PMID: 30459331 PMCID: PMC6244193 DOI: 10.1038/s41598-018-35582-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/07/2018] [Indexed: 01/13/2023] Open
Abstract
Unplanned extubation (UE) can be associated with fatal outcome; however, an accurate model for predicting the mortality of UE patients in intensive care units (ICU) is lacking. Therefore, we aim to compare the performances of various machine learning models and conventional parameters to predict the mortality of UE patients in the ICU. A total of 341 patients with UE in ICUs of Chi-Mei Medical Center between December 2008 and July 2017 were enrolled and their demographic features, clinical manifestations, and outcomes were collected for analysis. Four machine learning models including artificial neural networks, logistic regression models, random forest models, and support vector machines were constructed and their predictive performances were compared with each other and conventional parameters. Of the 341 UE patients included in the study, the ICU mortality rate is 17.6%. The random forest model is determined to be the most suitable model for this dataset with F1 0.860, precision 0.882, and recall 0.850 in the test set, and an area under receiver operating characteristic (ROC) curve of 0.910 (SE: 0.022, 95% CI: 0.867–0.954). The area under ROC curves of the random forest model was significantly greater than that of Acute Physiology and Chronic Health Evaluation (APACHE) II (0.779, 95% CI: 0.716–0.841), Therapeutic Intervention Scoring System (TISS) (0.645, 95% CI: 0.564–0.726), and Glasgow Coma scales (0.577, 95%: CI 0.497–0.657). The results revealed that the random forest model was the best model to predict the mortality of UE patients in ICUs.
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Affiliation(s)
- Meng Hsuen Hsieh
- Department of Electrical Engineering and Computer Science, University of California, Berkeley, Berkeley, California, USA
| | - Meng Ju Hsieh
- Department of Medicine, Poznan University of Medical Science, Poznan, Poland
| | - Chin-Ming Chen
- Department of Recreation and Health Care Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan. .,Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan.
| | - Chia-Chang Hsieh
- Department of Pediatrics, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
| | - Chih-Cheng Lai
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan.
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Ai ZP, Gao XL, Zhao XL. Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis. Intensive Crit Care Nurs 2018; 47:62-68. [PMID: 29653888 DOI: 10.1016/j.iccn.2018.03.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/24/2018] [Accepted: 03/30/2018] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To explore factors associated with unplanned extubation in Intensive Care Unit for adult patients. RESEARCH METHODOLOGY A systematic review and meta-analysis were performed of studies identified through Pubmed, CINAHL, Cochrane Library, PsycINFO and Web of Science published from initiation to September 2017. Only articles in English were included. The Newcastle-Ottawa Scale was used to evaluate the quality of the included articles. RESULTS Ten eligible studies were identified, encompassing a total of 2092 patients (457 in the unplanned extubation group; 1635 in the control group). The subsequent meta-analysis identified significant risk factors for unplanned extubation are male [odds ratio (OR) 1.54, 95% CI 1.12-2.12; P = 0.008], confusion [OR 0.10, 95% CI 0.05-0.17; P < 0.00001], physical restraint [OR 3.10, 95% CI 2.21-4.34; P < 0.00001], higher GCS scores [mean difference (MD) 1.06, 95% CI 0.59-1.52; P < 0.00001] and lower APACHE II scores [MD -2.26, 95% CI -3.35- -1.16; P < 0.0001]. Renal disease is a protective factor for unplanned extubation [OR 0.32, 95% CI 0.15-0.70; P = 0.004]. CONCLUSION Patients were male, confused, having physical restraint, with higher GCS and lower APACHE II scores are significant risk factors for unplanned extubation in Intensive Care Unit adult patients.
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Affiliation(s)
- Zhong-Ping Ai
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
| | - Xiao-Lan Gao
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xiao-Lei Zhao
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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19
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Cosentino C, Fama M, Foà C, Bromuri G, Giannini S, Saraceno M, Spagnoletta A, Tenkue M, Trevisi E, Sarli L. Unplanned Extubations in Intensive Care Unit: evidences for risk factors. A literature review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:55-65. [PMID: 29189706 PMCID: PMC6357578 DOI: 10.23750/abm.v88i5-s.6869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 11/07/2017] [Indexed: 11/26/2022]
Abstract
Background and aim: Unplanned extubations (UE) are getting more and more relevant in Critical Care, becoming a quality and care safeness outcome. This happens because after an UE the patient can face some complications concerning the airway management, respiratory and hemodynamic problems, lengthen in the hospital stay and in the mechanical ventilation time. The aim of this review is identify and classify the factors that could increase UE risk. Methodology: A systematic review of scientific articles was performed consulting the databases PubMed, Cinahl, Medline, EBSCOhost and Google Scholar. Articles from 2006 to 2011 were included. Pediatric Care settings were excluded. Results: 21 articles were selected. From the results emerged that risk factors associated to the patient are widely controversial. Yet restlessness, a low level of sedation and a high level of consciousness seem to be highly related to UE. Organizational risk factors, as workload, nurse:patient ratio, and the use of interdisciplinary protocols seem to play an important role in UE. Conclusion: According the current literature, the research on UE still has to handle a wide uncertainty. There is the need for more studies developing conclusive evidences on the role of different risk factors. Anyway, literature highlights the importance of the nurse and of the healthcare system organization in reducing UE incidence.
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