title: Unplanned extubation in the neonatal ICU: a systematic review, critical appraisal, and evidence-based recommendations.
abstract: OBJECTIVE
  To update the state of knowledge on unplanned extubations (UEs) in neonatal ICUs. This review focuses on the following topics: incidence, risk factors, reintubation after UE, outcomes, and prevention.
  
  
  METHODS
  The MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for relevant publications from January 1, 1950, through January 30, 2012. Fifteen articles were selected for data abstraction. The search strategy included the following key words: "unplanned extubation," "accidental extubation," "self extubation," "unintentional extubation," "unexpected extubation," "inadvertent extubation," "unintended extubation," "spontaneous extubation," "treatment interference," and "airway accident." Study quality was assessed using the Newcastle-Ottawa scale. Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine's levels of evidence system. Studies with Newcastle-Ottawa scale score ≥ 5 that included appropriate statistical analysis were deemed of high methodological quality.
  
  
  RESULTS
  The overall mean Newcastle-Ottawa scale score was 3.5. UE rates ranged from 0.14 to 5.3 UEs/100 intubation days, or 1% to 80.8%. Risk factors included restlessness/agitation (13-89%), poor fixation of endotracheal tube (8.5-31%), tube manipulation at the time of UE (17-30%), and performance of a patient procedure at bedside (27.5-51%). One study showed that every day on mechanical ventilation increased the UE risk 3% (relative risk 1.03, P < .001). The association between birth weight/gestational age and UE is controversial. Reintubation rates ranged from 8.3% to 100%. There is still a gap of information about strategies addressed to reduce the incidence of UE. The best method of endotracheal tube securement remains a controversial issue.
  
  
  CONCLUSIONS
  Despite numerous publications on UE, there are few studies assessing preventive strategies for adverse events and there is a lack of randomized clinical trials. Recommendations are proposed based on the current available literature.
authors.affiliation: Pediatric Intensive Care Unit, Department of Pediatrics, Hospital Sevidor Público Municipal, São Paulo, Brazil. psls.nat@terra.com.br.
authors.forename: Paulo Sérgio Lucas da
authors.initials: PS
authors.lastname: Silva
authors.forename: Maria Eunice
authors.initials: ME
authors.lastname: Reis
authors.forename: Vânia Euzébio
authors.initials: VE
authors.lastname: Aguiar
authors.forename: Marcelo Cunio Machado
authors.initials: MC
authors.lastname: Fonseca
mesh_terms: D000059:Accidents / Q000706:statistics & numerical data*; D060666:Airway Extubation / Q000706:statistics & numerical data*; D015331:Cohort Studies; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D012121:Respiration, Artificial / Q000009:adverse effects*; D019233:Retreatment / Q000379:methods / Q000706:statistics & numerical data; D012307:Risk Factors; D055502:Secondary Prevention / Q000379:methods / Q000706:statistics & numerical data