Reducing Unplanned Pediatric Extubations by Modifying Analgosedative Infusions

To decrease unplanned extubations (UEs), we aimed to reduce the use of fentanyl as the first-line opioid infusion for intubated patients in our combined pediatric and pediatric cardiac intensive care units by 10% within 1 year.

The quality improvement initiative began in July 2023 and focused on drivers such as education, sedation standardization, and data transparency. Education was provided to physicians, advanced practice practitioners, and nursing staff, with the creation of a sedative/analgesic infusion order set to standardize the ordering of morphine and hydromorphone for intubated patients admitted to the pediatric and pediatric cardiac intensive care units. We tracked data using statistical process control charts, shared at faculty meetings, and displayed on the unit to increase awareness.

During the baseline period (July 2022-June 2023), fentanyl was the first-line opioid infusion 45.5% of the time with 9 UEs. After implementation, first-line fentanyl infusions decreased to 18.1%. UEs also decreased to 5 from July 2023 to December 2024. The UE rate decreased from 1.03 per 100 ventilator days to 0.10 per 100 ventilator days during 1.5 years. We also observed improvements in the number of days between UE events, with a trend toward longer intervals.

Maintaining pediatric endotracheal tubes is multifactorial, with analgosedative infusions playing a prominent role. Adjusting the medication choice of first-line opioid infusions may be associated with a decrease in UE events.