title: Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations.
abstract: BACKGROUND
  In this study, we updated the state of knowledge on unplanned tracheal extubations in the intensive care unit. We focused on the following topics: incidence, risk factors, reintubation after unplanned extubation, outcomes, and prevention. Based on this review, recommendations were made for preventing unplanned extubations.
  
  
  METHODS
  Electronic databases were searched for relevant publications from January 1, 1950 through June 30, 2011 on the MEDLINE, EMBASE, CINAHL, SciELO, LILACS, and Cochrane systems. Fifty articles were eligible for data abstraction. Study quality was assessed using the Newcastle-Ottawa Scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine.
  
  
  RESULTS
  Unplanned extubations occur at a rate of 0.1 to 3.6 events per 100 intubation days. Risk factors associated with unplanned extubations included male gender (odds ratio [OR] 4.8), APACHE score ≥17 (OR 9.0), chronic obstructive pulmonary disease, restlessness/agitation (OR 3.3-30.6), lower sedation level (OR 2.0-5.4), higher consciousness level (OR 1.4-2.0), and use of physical restraints (OR 3.1). Reintubation rates ranged from 1.8% to 88% of unplanned extubations. Thirteen studies assessed preventive measures for avoiding unplanned extubations. These studies focused on data collection tools, standardization of procedures, staff education, staff surveillance, and identification and management of high-risk patients. These studies reported reductions in unplanned extubation rate from 22% to 53%. The best methods of securing the endotracheal tube and use of physical restraints remain controversial issues.
  
  
  CONCLUSIONS
  Despite numerous publications on unplanned extubation, few studies assess preventive strategies for adverse events, and few clinical trials have assessed unplanned extubations. Recommendations are proposed based on the currently available literature.
authors.affiliation: Department of Intensive Care Medicine, Hospital do Servidor Público Municipal, Rua Castro Alves, 60, São Paulo, Brazil, 01532-900. psls.nat@terra.com.br
authors.forename: Paulo Sergio Lucas
authors.initials: PS
authors.lastname: da Silva
authors.forename: Marcelo Cunio Machado
authors.initials: MC
authors.lastname: Fonseca
mesh_terms: D060666:Airway Extubation / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D000698:Analgesia; D019985:Benchmarking; D016022:Case-Control Studies; D015331:Cohort Studies; D016292:Procedural Sedation; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000379:methods; D008297:Male; D009726:Nurses / Q000706:statistics & numerical data; D012121:Respiration, Artificial; D012149:Restraint, Physical; D012307:Risk Factors; D012737:Sex Factors; D016896:Treatment Outcome; D015300:Ventilator Weaning