UNPLANNED EXTUBATION - RISK-FACTORS OF DEVELOPMENT AND PREDICTIVE CRITERIA FOR REINTUBATION

Objectives: To define patients at risk for unplanned extubation; to as sess the influence of nursing workload on the incidence of unplanned e xtubation; and to determine predictive criteria for pa patients requir ing reintubation. Design: A prospective, case control study, with 10 a nd 15 mos of data collection. Setting: University medical intensive ca re department. Patients: In the first study, which lasted 10 mos, unpl anned extubation occurred in 40 (14%) of 281 ventilated and intubated patients; 36 cases were sufficiently documented to be compared with 74 intubated and ventilated controls. In the second study, which lasted 15 mos, the reintubated patients (n = 23) of a series of 62 unplanned extubation patients were compared with those who were not reintubated (n = 39). Interventions: None. Measurements and Main Results: The foll owing parameters were recorded: gender, age, main reason for admission , Simplified Acute Physiology Score II, route of intubation (oral or n asotracheal), tube diameter, ventilatory mode, Flo(2),, frequency and tidal volume delivered by the ventilator immediately before unplanned extubation, arterial blood gases performed 24 hrs before unplanned ext ubation, the presence of any sedation with, in this case, the last Ram say score, the presence of hand restraints, the presence of weaning of ventilation, the accidental or deliberate nature of unplanned extubat ion, the Glasgow Coma Score at the time of unplanned extubation, the d uration of ventilation before unplanned extubation, total duration of ventilation and stay in the intensive care unit, and the patient's sur vival or death. The nursing workload was evaluated using a score deriv ed from the Project de Recherche en Nursing and adapted to intensive c are. Unplanned extubation patients were more frequently intubated oral ly than controls (33.3% vs. 14.9%, respectively; p<.05). In the popula tion of sedated patients, unplanned extubation patients were more freq uently agitated than controls (60% vs. 19%, respectively; p<.05). The nursing workload did not differ between days with and days without unp lanned extubation. Twenty-three (37%) of the 62 cases of documented un planned extubation were reintubated. Predictive factors of reintubatio n are, in decreasing order of importance: Glasgow Coma Score of <11, a ccidental nature of unplanned extubation, and a Pao(2)/Flo(2), ratio < 200 torr (<26.7 kPa). Conclusions: Patients at risk for unplanned extu bation are characterized by oral intubation and insufficient sedation. In the department studied, and with the specific score used, we did n ot observe a relationship between the nursing workload and the inciden ce of unplanned extubation. A Glasgow Coma Score of <11, the accidenta l nature of unplanned extubation, and a Pao(2)/Flo(2), ratio <200 torr (<26.7 kPa) are factors associated with a risk of reintubation.