Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations.
OBJECTIVE
The aim of this study was to update the state of knowledge of unplanned extubations in the pediatric population. The main topics addressed in the current literature on unplanned extubations were: 1) incidence; 2) risk factors; 3) risk factors for reintubation after unplanned extubations; and 4) strategies to prevent unplanned extubations. Based on this review we summarize and propose best practices in preventing unplanned extubations.


METHODS
MEDLINE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for bibliography for the period spanning from January 1966 to March 2009. We used the following key words: unplanned extubation, accidental extubation, self extubation, unintentional extubation, unexpected extubation, inadvertent extubation, spontaneous extubation, and treatment interference.


METHODS
Eleven pediatric articles were eligible for data abstraction. Study quality was assessed using four levels of aggregate evidence adapted from the American Academy of Pediatrics.


RESULTS
Unplanned extubations occurs at a rate of 0.11 to 2.27 events per 100 intubation days. Risk factors associated with unplanned extubations were age (younger patients), inadequate tube fixation, agitation, copious secretions, performance of patient procedures, and nursing workload. Reintubation rates ranged from 14% to 65% of unplanned extubations. Three cohort studies evaluated the effectiveness of strategies in reducing unplanned extubations. One study reported the institution of a standardized algorithm of goal-directed sedation, whereas two studies evaluated the implementation of a continuous quality-improvement program. These studies reported significant reductions in unplanned extubations rate after program implementation. Methods of securing the endotracheal tube varied across studies and the use of physical restraints yielded conflicting findings.


CONCLUSIONS
There are few studies assessing unplanned extubations in pediatric intensive care units. The available quality studies have shown that improvement of quality components is effective in reducing unplanned extubations. Although further rigorous studies are needed to establish strong recommendations on unplanned extubations prevention, we present a summary of recommendations based on review of the current literature.
Lucas da Silva
Paulo Sérgio
PS
Division of Pediatric Critical Care Medicine, Universidade Federal de São Paulo, São Paulo. psls.nat@terra.com.br
de Carvalho
Werther Brunow
WB
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D020878:Device Removal / Q000592:standards*; D055317:Evidence-Based Practice; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007442:Intubation, Intratracheal / Q000295:instrumentation*; D012307:Risk Factors