A self-extubation case series in an ICU after the introduction of an early mobilization project

Abstract

Background: Recent studies demonstrate that early mobilization of patients with acute respiratory failure reduces ICU and hospital length of stay.  This patient care activity necessarily requires coordinated efforts by ICU personnel and alert patients and has the potential for adverse outcomes, including unplanned extubation. Methods: Our intensive care unit introduced an early mobilization quality improvement project in April 2014.  This project involved an eight step program which was started as soon as the patient was medically stable. The nurse managers kept a log of patients who participated in this project and a log of all patients who self-extubated during this period. Results: Twenty-five patients self-extubated during this time period; the event rate was 1.1 episodes per week in a 31 bed ICU.  The mean age was 46.8 ± 13.6 years; 64% were men. The initial indications for mechanical ventilation in these patients included respiratory disease (40%), sepsis (4%), encephalopathy (8%), and miscellaneous diagnoses (48%). Initial chest x-ray readings included clear lung fields, infiltrates, effusions, and other abnormalities. Twelve episodes occurred on the day shift, and 13 episodes occurred on the night shift.  The most recent Glasgow Coma Scale score in these patients was 11.8 (mean) with a range of 8-15. Eighty percent of the patients were restrained, 40% were on analgesics, and 56% were on sedatives.  The mean FiO2 at the time of self-extubation was 57.3 ± 29%, and the mean PEEP level was 5.4 ± 1.5 cm H2O.  Seven patients (28%) required reintubation. None of these patients in the early mobilization project had an episode of self-extubation. Conclusions: The patients who self-extubated in our ICU had no unique characteristics which might help us identify them before these events occurred. This did not occur in the patients in the early mobilization project. Self-extubation events provide a good monitor for ICU care.  In our ICU the frequency of reintubation was low, and this might suggest that we need to manage our weaning protocols better with earlier extubation in some patients.