Unplanned Extubation in PICU and Its Adverse Impact: A Case-Control Study

Unplanned extubations are adverse events with multifactorial causes, involving both patient characteristics and organizational features in Paediatric Intensive Care Units (PICUs).

To identify the main clinical and contextual determinants associated with unplanned extubations in PICU patients.

We conducted a case-control retrospective observational study at a paediatric hospital in Eastern Andalucia (Spain). Cases were patients who experienced an unplanned extubation, and controls were those who did not during the same period.

A total of 121 active cases and 275 controls were included, yielding a rate of 5.07 events per 100 ventilated patients. For the 2902 invasively ventilated children, 147 unplanned extubations occurred in 121 children (4.17% of children experienced at least one event). Unplanned extubations occurred more frequently in patients receiving assisted ventilation (OR = 2.52; 95% CI: 1.56-4.07). The mean additional length of stay in the PICU for cases was 7.5 days. Independent predictors for unplanned extubations included male sex (OR = 0.87; 95% CI: 0.47-1.63), older age (OR = 1.01; 95% CI: 0.99-1.02), use of assisted-spontaneous ventilatory modes (OR = 2.47; 95% CI: 1.18-5.19), lower doses of midazolam (OR = 24.28; 95% CI: 1.57-11.62), and nurse overallocation (OR = 2.05; 95% CI: 1.19-3.53).

Unplanned extubations in PICU are influenced by both clinical factors and organizational aspects of care. Notably, most predictors identified (e.g., sedation practices, nurse staffing) are modifiable, indicating the potential for targeted interventions to reduce this adverse event.

Preventing unplanned extubations is critical for safeguarding paediatric patients. By optimizing nursing ratios, sedation regimens, and care protocols, PICUs can reduce the incidence of accidental extubations, thereby improving patient outcomes and minimizing prolonged lengths of stay. These findings should be used by healthcare managers to systematically evaluate the consequences of a severe adverse effect such as unplanned extubations (UE) and introduce quality improvement actions to minimize the consequences on patient safety and PICU outcomes.