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MORBIDITY & MORTALITY CONFERENCE BLISS 11I

Omar Shahbaz - PGY 3Omar Shahbaz - PGY 3

Bhavtosh Dedania - PGY 2Bhavtosh Dedania - PGY 2

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Patient-related factors Restlessness Agitation Confusion Physical suffering Nosocomial infection Nasotracheal intubation

Nursing Related Factors Poor fixation of the endotracheal tube High patient to nurse ratios Night shift

Risk Factors Associated with Risk Factors Associated with Unplanned ExtubationUnplanned Extubation

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Physical Restraints:Physical Restraints:(1)

(+) Restraining an unconscious/restless patient might prevent self-extubation

(-) Restraints might cause anxiety and increase the possibility of unplanned extubation

**Self-extubation occurs despite the use of restraints. Nonetheless remains first choice in high risk patients.

Sedation:Sedation:(2)

Sedation increases the risk for unplanned extubation by prolonging mechanical ventilation and initiating paradoxical agitation

1) Happ MB. Treatment interference in critically ill patients: an update on unplanned extubation. Clin Pulmon Med. 2002; 9:81-86)

2) Chang et al. Influence on physical restraint on unplanned extubation in adult intensive care patients: a case-control study. Am J Crit Care 2008:17:408-415

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Among the 191 patients who were physically restrained 82 had unplanned extubation

Age, Apache II score, GCS scores, restraint method, route of intubation, sedative status DID NOT differ significantly between the unplanned extubation group and the control group

The unplanned extubation group had a higher rate of nosocomial infection vs. control group (29.3% vs. 15.2%)

-------------------------------------------- Among the 109 patients who were

never physically restrained, 18 had unplanned extubation.

No significant difference in Age, Apache II scores, route of intubation, rates of nosocomial infection or sedative status

The unplanned extubation group had higher GCS scores on ICU admission vs. control group (10.3% vs. 8.3%)

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Consequences of Unplanned ExtubationConsequences of Unplanned Extubation

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Types of Self ExtubationTypes of Self Extubation

Accidental ExtubationAccidental Extubation Self Extubation Self Extubation

Inappropriate manipulation of tube during patient care

Cause : Non purposeful patient’s action e.g cough / sneezing

All NATURAL or UNINTENTIONAL causes

Lower risk of adverse outcomes than Self extubation.

Patient’s deliberate or intentional action

Reason –discomfort of tube / pain / agitation / no-restraints / delirium / encephalopathy / inability to breathe on their own etc

Higher risk of adverse outcomes than accidental extubation.

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85 year old demented male admitted since last 2 weeks for COPD exacerbation due to strep PNA self extubated noticed by

RN call for RT – starts bagging the pt Intern / PA – o/n stat page Secretary (“Anesthesia Stat Bliss 11i room 5” X 3) Resident admitting in red pod (finishing his H&P /

orders) runs from ED to 11i Anesthetist & team ( whats the K+ , Mg+2,

history, meds) Re-intubation Stat CXR – for tube placement Radiologist calls back ICU attending notified in the middle of night

Hypothetical Situation 2:30 AM on Hypothetical Situation 2:30 AM on Saturday nightSaturday night

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Chaotic situation because its unplanned and pt. is not ready

Issue with patient safety ET removed with INFLATED cuff – higher damage Circulatory and reflex changes – Bradycardia /

Tachycardia / Hypotension Laryngospasm / Laryngeal Edema / Bronchospasm

(Coppolo and May, 1990; Atkins et al., 1997; Mort, 1998).

Higher risk of Pneumonias (aspiration in particular) with emergent intubation (de Lassence et al., 2002)

Higher risk of injury – mechanical due to laryngoscope / ET tube – chance of bleeding & difficult re-intubation due to edema

Arrhythmias Adverse outcomes including death

ConcernsConcerns

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Re-intubated patients demonstrate up to sevenfold higher ICU or hospital mortality rates compared with those who successfully tolerate UE (Epstein et al., 1997; Robin and Trieger, 2002; Bouza et al., 2007)

Besides mortality, re-intubation is associated with significantly higher incidence of ICU-acquired urinary tract infections (de Lassence et al., 2002; Krinsley and Barone, 2005)

Prolonged duration of mechanical ventilation, ICU and hospital length of stay (Epstein et al., 2000; Johan, 2000; Bouza et al., 2007)

Higher resource utilization (Krinsley and Barone, 2005).

Contd.Contd.

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Hypotension - 35%Tachycardia - 30%Hypertension - 14%Multiple laryngoscopy attempts - 22%Difficult laryngoscopy - 16%Difficult intubation - 14%Hypoxemia - 14%Esophageal intubation - 14%

Immediate Complications : Immediate Complications : Breaking it downBreaking it down

(Anesth Analg 2012;114:1003–14)

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Unplanned Extubation (UE) is expressed as the number of episodes observed per 100 ventilated days.

National average 3 to 16% Our Hartford Hospital average 4.14 %

..\..\..\Downloads\Bliss 11I.xlsx Most patients were reintubated within 1 hour of

unintentional extubation. Reintubation rates were slightly higher in medical

patients than surgical patients. Reintubation was less frequent during weaning from

mechanical ventilation, compared with patients on continuous ventilatory support

Patients who extubated themselves had lower reintubation rates than accidental extubation

DataData

Courtesy : Dr. Shore & RT staff

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A prospective study by Tominaga et al assessing 2 time periods found that decreased use of hand restraints increased the incidence of unplanned extubations (2% vs 6%, P 0.001)

Carrion et al.31 suggested keeping patients’ hands at least 20 cm away from endotracheal tubes to prevent unplanned extubation.

The most common type of restraint was the wrist belt, but use of chest restraint ,4-point, arm, and hand restraints were also described

1. Physical Restraints1. Physical Restraints

(Anesth Analg 2012;114:1003–14)

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Tominaga et al.19 found fewer unplanned extubations when tubes were secured with waterproof tape around the tube, upper lip, and face compared with an endotracheal tube secured via a cloth or Velcro tie around the back of the head (15% vs 4%, P 0.001).

Barnason et al.28 showed that securing the endotracheal tube using twill or adhesive tape was comparable in preventing unplanned extubations and maintaining oral mucosa and facial skin integrity.

Richmond et al.5 found that securing endotracheal tubes with a Comfit or Hollister holder reduced the incidence of unplanned extubations.

2. Securing the ET tube2. Securing the ET tube

(Anesth Analg 2012;114:1003–14)

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Two studies associated the use of benzodiazepines, particularly midazolam, with an increased occurrence of unplanned extubations. Although a paradoxical excitatory effect or delirium associated with midazolam has been identified as a probable explanations for this finding.

IV boluses of morphine sulfate, benzodiazepines (diazepam, midazolam, or lorazepam), and haloperidol given “as needed” were found to increase the incidence of unplanned extubations.

‘Powers’ reported that the introduction of a sedation protocol linked to the RAAS reduced the incidence of unplanned extubation from 7% to 3% in 1 year.

3. Sedation3. Sedation

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Six studies found a correlation between higher unplanned extubation rate and

Increased nursing workload Nurse experience of 5 years or less Nurse absence from the room.

The health care provider was not at the bedside at the time of unplanned extubations in 71% to 89%of cases.

4. Nursing care4. Nursing care

(Anesth Analg 2012;114:1003–14)

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Thirteen studies recommended prompt identification of patients ready for weaning from mechanical ventilation as a strategy to reduce unplanned extubation.

This recommendation was based on the finding that most patients who successfully tolerated unplanned extubation, suggesting they were eligible for elective extubation within the ensuing few hours.

5. Weaning5. Weaning

(Anesth Analg 2012;114:1003–14)

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Be prepared Identify high risk patient by using risk assessment tool Artificial manual breathing unit (AMBU) bag in room

of all intubated patients Respiratory Therapist in ICU Oral Care Adequate & frequent suctioning Appropriate size of tube holders & tube fixation

techniques Securing the ET tube while patient positioning or

bathing Ix & Rx of agitation – sedatives, analgesics, improved

orientation, behavior therapy , visits of relatives.

SummarySummary

Nursing in Critical Care © 2012 British Association of Critical Care NursesIntensive and Critical Care Nursing (2007) 23, 249—255

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Increased RN staffing esp. for sick high risk pts , 1:1 Implementation of CME for nursing education Weaning protocol – wake up and breath, to extubate

before UE event Judicious use of physical restraints, as can be harmful Protocols for patient transport The use of non-invasive positive pressure ventilation

in patients whose UE occurred during the weaning period has the potential to considerably decrease the need for re-intubation

SummarySummary

Nursing in Critical Care © 2012 British Association of Critical Care NursesIntensive and Critical Care Nursing (2007) 23, 249—255

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