Original contribution
The relationship of sedation to deliberate self-extubation

Presented in part at the Associated Professional Sleep Society annual meeting, Las Vegas, NV, June 19, 2000.
https://doi.org/10.1016/S0952-8180(00)00237-3Get rights and content

Abstract

Study Objectives: To evaluate the relationship between sedative therapy and self-extubation in a large medical-surgical intensive care unit (ICU).

Design: Retrospective, case-controlled study.

Setting: Large teaching hospital.

Patients: All adult patients who underwent unplanned self-extubation during a 12-month period (n = 50). Each patient was matched to two control patients who did not self-extubate based on age, gender, dates in hospital and diagnosis.

Interventions: none.

Measurements: Data collected included time to self extubation, dosages and types of benzodiazepines, opioid analgesics, antipsychotics, and hypnotics. Data on the degree of agitation as assessed by nursing staff also were obtained.

Main results: When compared to controls, patients in the self-extubation group were more likely to have received benzodiazepines (59% vs. 35%; p < 0.05), but equally likely to have received opioids and/or paralytic drugs. Patients who self-extubated were twice as likely as controls to be agitated (54% vs. 22%; p < 0.05). Use of benzodiazepines was more common in agitated patients than in nonagitated patients (62% vs. 35%; p < 0.02). Among nonagitated patients who self-extubated, increased use of benzodiazepines (57% vs. 29%; p < 0.05) was noted when compared to nonagitated controls.

Conclusions: In intubated ICU patients, benzodiazepines may not consistently treat agitation effectively or prevent self-extubation. Such an effect may be due to paradoxical excitation, disorientation during long-term administration, or differences in drug administration between ICU and operating room (OR) environments.

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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Assistant Professor of Anesthesia

Fellow, Sleep Research Laboratory

Staffnurse

§

Director, Geriatric Nursing Program

Section head, Geriatrics

∗∗

Researcher, Department of Bioethics

††

Professor of Psychiatry, Pharmacology, and Medicine

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