Clinico-etiological profile of children who had unplanned extubation and subsequent re-intubation in level-4 pediatric intensive care unit

Abstract

Background: There are few studies on unplanned extubation (UE) in pediatric intensive care units (PICU). This study is to identify factors associated with UE in PICUs.Subjects and Methods: In this observational study, the data of UE from January 1, 2013, to May 31, 2019, in a level-4 PICU were analyzed with an objective to study the etiology of UE and its impact on therapeutic outcomes.Results: Of 7079 patients hospitalized in PICU, 1721 were invasively ventilated (mean ventilator days 4.33 days). UE occurred in 39 patients (2.26% of intubated patients) at 0.52 UE events per 100 ventilation days. The median age was 14 months. The most common cause of UE was inadequate sedation (n = 24, 61.53%), endotracheal tube suctioning (n = 05, 20.8%), one during adjusting ET tube (4.1%), one during central venous line insertion (4.1%), and one during Foley's catheter insertion (4.1%) and 7 unexplained (29.1%). As long as the appropriate nurse: patient ratio was maintained, the incidence of UE was un-affected by day versus night shift or high versus low bed occupancy rates. Re-intubation rate in UE cohort was higher (74.35%) than planned-extubation cohort 0.11% (P < 0.001). All re-intubations were within 2 h of UE. Most common cause of re-intubation following UE was respiratory distress (72.41%), stridor (17.24%), and apnea (10.34%). Re-intubations following UE showed higher incidence of ventilator-associated pneumonia but statistically not significant (P = 0.54).Conclusion: UE is associated with a significantly high incidence of re-intubations and associated complications arising from re-intubations. Maintaining a pool of skilled nurses in adequate nurse-to-patient ratio may play an important role in preventing UE. UE can be minimized by optimizing sedation and monitoring during common ICU procedures. Multicentric studies are warranted to design a uniform standard of care of ventilated patients aimed at reducing the incidence of UE.