Original contributionThe relationship of sedation to deliberate self-extubation
Introduction
Critically ill patients often require endotracheal intubation for airway protection or respiratory failure. Because intubation is associated with complications such as infection and aspiration, patients are kept intubated only when necessary, and precautions are taken to prevent unplanned or self-extubation. Ventilator alarms, increased nursing coverage, use of sedative and paralytic drugs, and physical restraints are examples of strategies used in patients at risk for unplanned extubation.
Despite these precautions, the incidence of unplanned self-extubation in critical care units ranges from 11% to 16%.∗1 Furthermore, the process of unplanned self-extubation followed by reintubation in critically ill patients has been associated with severe morbidity or death.3 Although precipitating factors such as inadequate tube taping, duration of intubation, and time of day have been suggested,1, 2, 3, 4 to date, no complete examination of all the factors associated with self-extubation has been performed.
In particular, the role of sedative and paralytic drugs in preventing self-extubation is unclear. Although the short-term use of sedatives may reduce anxiety and prevent unwanted activity, long-term use may have significant cognitive consequences. Extended use of sedatives may exacerbate agitation and irrational behavior, perhaps by altering sleep/wake cycles or disrupting circadian rhythms. In addition, differences in administration of sedatives between the intensive care unit (ICU) and the operating room (OR) may make sedatives less effective when administered in an ICU environment.
To explore the possible effect of sedative and paralytic drugs on self-extubation, we analyzed unpublished data from a previously published case control study of self-extubation at a major teaching hospital.5 We compared data on sedative, opioid, and paralytic use between 50 patients who self-extubated during a one-year period and 100 matched controls in the ICUs of a major tertiary-care center.
Section snippets
Materials and methods
Patient characteristics and methods in the case-control study have been published previously.5 The study was performed at the Cleveland Clinic Foundation (CCF), which is a 1000-bed national referral center. CCF has nine adult ICUs in which more than 2000 patients per year are mechanically ventilated.
Adult patients for whom occurrences of self-extubation were witnessed by nursing staff during 1993 were studied (n = 50). Self-extubation was defined as nonmedically recommended patient removal of
Results
The original study sample consisted of 150 patients: 50 who had self-extubated each matched by age, gender, dates in hospital, and diagnosis to 2 patients who had not. Complete drug information was available on 46 of the 50 patients in the self-extubation group and all 100 patients in the control group. All patients were orally intubated. When documented, all subjects had the ETT secured by adhesive tape. Self-extubation subjects had been intubated for a longer, but not statistically
Discussion
An important goal of sedation in the ICU is to facilitate patient cooperation with endotracheal intubation. Although intubated patients are frequently sedated to avoid inadvertent self-extubation, it is unclear whether the use of sedation aids in preventing such events. When compared to accidental extubations, Vassal et al.4 noted increased agitation in patients who deliberately self-extubated and concluded that inadequate sedation played a role. Coppolo et al.,1 however, found that 7 of 9
Acknowledgements
The authors thank Thomas Franko for his assistance with data collection and analysis.
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Cited by (49)
Superficial placement of endotracheal tubes associated with unplanned extubation: A case-control study
2022, Journal of Critical CareCitation Excerpt :The other studies reflect the historical practice of using midazolam as a first line sedative. Midazolam was associated with UE in their case [8,26], but as midazolam is no longer used as a first-line sedative, this finding was not replicated in this study results. Given the common practice of using propofol or fentanyl in our units, it is not surprising to find that these agents were associated with unplanned extubation.
Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis
2018, Intensive and Critical Care NursingCitation Excerpt :For the case control studies, the participants of the no UE group in three of the studies were randomly selected, others were according to case matching. In all the case matching studies, all of them (Chang et al., 2011; Tung et al., 2001; Chang et al., 2008; Atkins et al., 1997) matched cases and controls on basis of gender, age and dates in hospitals, while three of them matched cases and controls on basis of diagnosis (Chang et al., 2011; Tung et al., 2001; Chang et al., 2008), therefore, these studies were taken out of the analysis to assess the impact of these factors on the risk for UE. And for the cohort studies, all the patients were included during the study period.
Self/Unplanned Extubation. Safety, Surveillance, and Monitoring of the Mechanically Ventilated Patient
2012, Critical Care Nursing Clinics of North AmericaCitation Excerpt :It is important to limit the use of these devices to clinically appropriate situations, and only when alternative measures to reduce the patient's anxiety or agitation have failed.34 For nearly 20 years, studies have shown that physical restraints are not effective at preventing UE.24,35–39 Patients who are physically restrained have been shown to have a higher rate of unplanned extubation than those who are not restrained.
Influence of sedation strategies on unplanned extubation in a mixed intensive care unit
2014, American Journal of Critical CareA retrospective analysis of the incidence and determinants of self-extubation in a tertiary care surgical intensive care unit
2023, Anaesthesia, Pain and Intensive CareAnalytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches
2023, Journal of Intensive Care Medicine
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Assistant Professor of Anesthesia
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Fellow, Sleep Research Laboratory
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Staffnurse
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Director, Geriatric Nursing Program
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Section head, Geriatrics
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Researcher, Department of Bioethics
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Professor of Psychiatry, Pharmacology, and Medicine