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Unplanned extubation in the neonatal ICU: a systematic review, critical appraisal, and evidence-based recommendations
Paulo Sérgio Lucas da Silva1, Maria Eunice Reis, Vânia Euzébio Aguiar
1Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sevidor Público Municipal, São Paulo, Brazil. psls.nat@terra.com.br.
Insights
Unplanned extubations (UEs) in neonatal ICUs are common, with agitation and poor tube fixation as key risk factors. More research is needed on effective prevention strategies to reduce adverse events.
Area of Science:
- Neonatal Intensive Care
- Pediatric Critical Care
- Respiratory Therapy
Background:
- Unplanned extubation (UE) is a significant concern in neonatal intensive care units (NICUs).
- Existing literature highlights various risk factors and outcomes associated with UEs.
- A comprehensive update on the current knowledge regarding UEs is warranted.
Purpose of the Study:
- To synthesize current knowledge on unplanned extubations in NICUs.
- To review the incidence, risk factors, reintubation rates, outcomes, and prevention strategies for UEs.
- To identify gaps in the literature, particularly concerning preventive measures.
Main Methods:
- A systematic literature search was conducted across multiple databases (MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, Cochrane) from 1950 to 2012.
- Fifteen articles were selected for data abstraction and quality assessment using the Newcastle-Ottawa scale.
- Key search terms included various forms of "unplanned extubation" and related phrases.
Main Results:
- UE rates varied widely (1% to 80.8%), with restlessness/agitation and poor endotracheal tube fixation identified as major risk factors.
- Each day on mechanical ventilation increased UE risk by 3%. Reintubation rates after UE were high (8.3% to 100%).
- The association between birth weight/gestational age and UE remains controversial, and effective securement methods are debated.
Conclusions:
- Despite numerous publications, there is a lack of high-quality studies, especially randomized clinical trials, on UE prevention strategies.
- Current evidence suggests a significant incidence and associated risks of UEs in NICUs.
- Recommendations for prevention are proposed based on available literature, acknowledging existing knowledge gaps.
Objective:
To update the state of knowledge on unplanned extubations (UEs) in neonatal ICUs. This review focuses on the following topics: incidence, risk factors, reintubation after UE, outcomes, and prevention.
Methods:
The MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for relevant publications from January 1, 1950, through January 30, 2012. Fifteen articles were selected for data abstraction. The search strategy included the following key words: "unplanned extubation," "accidental extubation," "self extubation," "unintentional extubation," "unexpected extubation," "inadvertent extubation," "unintended extubation," "spontaneous extubation," "treatment interference," and "airway accident." Study quality was assessed using the Newcastle-Ottawa scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine's levels of evidence system. Studies with Newcastle-Ottawa scale score ≥ 5 that included appropriate statistical analysis were deemed of high methodological quality.
Results:
The overall mean Newcastle-Ottawa scale score was 3.5. UE rates ranged from 0.14 to 5.3 UEs/100 intubation days, or 1% to 80.8%. Risk factors included restlessness/agitation (13-89%), poor fixation of endotracheal tube (8.5-31%), tube manipulation at the time of UE (17-30%), and performance of a patient procedure at bedside (27.5-51%). One study showed that every day on mechanical ventilation increased the UE risk 3% (relative risk 1.03, P < .001). The association between birth weight/gestational age and UE is controversial. Reintubation rates ranged from 8.3% to 100%. There is still a gap of information about strategies addressed to reduce the incidence of UE. The best method of endotracheal tube securement remains a controversial issue.
Conclusions:
Despite numerous publications on UE, there are few studies assessing preventive strategies for adverse events and there is a lack of randomized clinical trials. Recommendations are proposed based on the current available literature.
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