title: Influence of sedation strategies on unplanned extubation in a mixed intensive care unit.
abstract: BACKGROUND
  Identifying risk factors for unplanned extubation in patients receiving mechanical ventilation can help guide prevention strategies.
  
  
  OBJECTIVE
  To assess the risk of unplanned extubation with different sedation strategies.
  
  
  METHODS
  A 36-month quality improvement study in a 33-bed intensive care unit at a tertiary-care center.
  
  
  RESULTS
  A total of 92 unplanned extubations occurred (7.5 events/1000 days of mechanical ventilation): patients who were receiving continuous sedation protocol with daily interruption of sedatives had 1.5 events/1000 ventilator days, patients receiving the intermittent sedation protocol had 5.0 events/1000 days, and patients with no sedation protocol had 16 events/1000 days (P < .05). Median duration of mechanical ventilation before unplanned extubation was 2 days. Most unplanned extubations (94%) were deliberate, and 53% occurred in patients scheduled for weaning. Most unplanned extubations in the continuous sedation protocol group (71%) occurred during weaning, in comparison to the intermittent sedation protocol (54%) and no sedation protocol groups (48%, P< .05). The highest incidences of agitation were in patients receiving the intermittent sedation protocol as compared with the other 2 groups (77% vs 50% vs 49%, P < .05). Overall, 73% of patients who had an unplanned extubation did not require reintubation; those who did were older (mean age: 68 vs 53 years, P = .01) and were male (80% vs 20%, P= .02). Reintubation was unrelated to the time of unplanned extubation.
  
  
  CONCLUSIONS
  Strategies of no sedation or intermittent sedation are both associated with higher rates of unplanned extubation when compared to a strategy of continuous sedation with daily interruption of sedatives. Sedation strategies that allow agitation may increase the risk of unplanned extubation.
authors.affiliation: Maged Tanios is an associate clinical professor of medicine, University of California Irvine, Irvine, California, and director of the medical intensive care unit, Long Beach Memorial Medical Center, Long Beach, California. Scott Epstein is dean for educational affairs and professor of medicine, Tufts University School of Medicine, Boston, Massachusetts. Mark Grzeskowiak is manager, education and quality, Department of Respiratory Care Services, and Hyunsoon Park is a clinical nurse specialist in the intensive care unit, Long Beach Memorial Medical Center. Huan Mark Nguyen is an assistant professor of pharmacy practice, Western University of Health Sciences, College of Pharmacy, Pomona, California. James Leo is medical director, best practice and clinical outcomes, MemorialCare Health System, Fountain Valley, California. mtanios@memorialcare.org.
authors.forename: Maged
authors.initials: M
authors.lastname: Tanios
authors.affiliation: Maged Tanios is an associate clinical professor of medicine, University of California Irvine, Irvine, California, and director of the medical intensive care unit, Long Beach Memorial Medical Center, Long Beach, California. Scott Epstein is dean for educational affairs and professor of medicine, Tufts University School of Medicine, Boston, Massachusetts. Mark Grzeskowiak is manager, education and quality, Department of Respiratory Care Services, and Hyunsoon Park is a clinical nurse specialist in the intensive care unit, Long Beach Memorial Medical Center. Huan Mark Nguyen is an assistant professor of pharmacy practice, Western University of Health Sciences, College of Pharmacy, Pomona, California. James Leo is medical director, best practice and clinical outcomes, MemorialCare Health System, Fountain Valley, California.
authors.forename: Scott
authors.initials: S
authors.lastname: Epstein
authors.affiliation: Maged Tanios is an associate clinical professor of medicine, University of California Irvine, Irvine, California, and director of the medical intensive care unit, Long Beach Memorial Medical Center, Long Beach, California. Scott Epstein is dean for educational affairs and professor of medicine, Tufts University School of Medicine, Boston, Massachusetts. Mark Grzeskowiak is manager, education and quality, Department of Respiratory Care Services, and Hyunsoon Park is a clinical nurse specialist in the intensive care unit, Long Beach Memorial Medical Center. Huan Mark Nguyen is an assistant professor of pharmacy practice, Western University of Health Sciences, College of Pharmacy, Pomona, California. James Leo is medical director, best practice and clinical outcomes, MemorialCare Health System, Fountain Valley, California.
authors.forename: Mark
authors.initials: M
authors.lastname: Grzeskowiak
authors.affiliation: Maged Tanios is an associate clinical professor of medicine, University of California Irvine, Irvine, California, and director of the medical intensive care unit, Long Beach Memorial Medical Center, Long Beach, California. Scott Epstein is dean for educational affairs and professor of medicine, Tufts University School of Medicine, Boston, Massachusetts. Mark Grzeskowiak is manager, education and quality, Department of Respiratory Care Services, and Hyunsoon Park is a clinical nurse specialist in the intensive care unit, Long Beach Memorial Medical Center. Huan Mark Nguyen is an assistant professor of pharmacy practice, Western University of Health Sciences, College of Pharmacy, Pomona, California. James Leo is medical director, best practice and clinical outcomes, MemorialCare Health System, Fountain Valley, California.
authors.forename: Huan Mark
authors.initials: HM
authors.lastname: Nguyen
authors.affiliation: Maged Tanios is an associate clinical professor of medicine, University of California Irvine, Irvine, California, and director of the medical intensive care unit, Long Beach Memorial Medical Center, Long Beach, California. Scott Epstein is dean for educational affairs and professor of medicine, Tufts University School of Medicine, Boston, Massachusetts. Mark Grzeskowiak is manager, education and quality, Department of Respiratory Care Services, and Hyunsoon Park is a clinical nurse specialist in the intensive care unit, Long Beach Memorial Medical Center. Huan Mark Nguyen is an assistant professor of pharmacy practice, Western University of Health Sciences, College of Pharmacy, Pomona, California. James Leo is medical director, best practice and clinical outcomes, MemorialCare Health System, Fountain Valley, California.
authors.forename: Hyunsoon
authors.initials: H
authors.lastname: Park
authors.affiliation: Maged Tanios is an associate clinical professor of medicine, University of California Irvine, Irvine, California, and director of the medical intensive care unit, Long Beach Memorial Medical Center, Long Beach, California. Scott Epstein is dean for educational affairs and professor of medicine, Tufts University School of Medicine, Boston, Massachusetts. Mark Grzeskowiak is manager, education and quality, Department of Respiratory Care Services, and Hyunsoon Park is a clinical nurse specialist in the intensive care unit, Long Beach Memorial Medical Center. Huan Mark Nguyen is an assistant professor of pharmacy practice, Western University of Health Sciences, College of Pharmacy, Pomona, California. James Leo is medical director, best practice and clinical outcomes, MemorialCare Health System, Fountain Valley, California.
authors.forename: James
authors.initials: J
authors.lastname: Leo
mesh_terms: D000328:Adult; D000368:Aged; D060666:Airway Extubation; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007362:Intensive Care Units; D007442:Intubation, Intratracheal; D008297:Male; D008875:Middle Aged; D011595:Psychomotor Agitation / Q000150:complications; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D062606:Tertiary Care Centers; D016312:Treatment Refusal; D015300:Ventilator Weaning
chemical_list: D006993:Hypnotics and Sedatives