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What does research reveal about how and why do unplanned extubations occur? How dangerous are unplanned extubations? We dive into it deep in this episode.

Episode Transcription

One of the common foundational reasons for giving sedation automatically after intubation is for an inherited sense of safety. Between being uneducated about the risks and repercussions of sedation and immobility and being taught that patients will automatically pull their endotracheal tubes out if they’re awake enough to move has nourished the shared belief that “if I stop my patient from moving, I keep them safer.”

You probably have had some traumatizing experiences with wrestling a patient to stop them from pulling their ETT tube or finding a patient that has self-extubated and needs emergency reintubation. Nurses especially take their responsibility as stewards of patient safety as sacred. So this is a huge hurdle to address when we discuss avoiding sedation for intubated patients on mechanical ventilation. So this episode, let’s dive into the whole mess and hit it hard.

We’re going to talk about unplanned extubations. 63% of unplanned extubations are the dreaded self-extubations, and the other 37% are any other kind of accidental extubation that was not an intentional removal of the endotracheal tube by clinicians (2). Unplanned extubations have been studied, but studies have been done in variable ways, with different measurements, sample sizes, methods, etc… and so it’s not surprising that they provide conflicting conclusions.

So I’m going to try to give a fair overview of what is in the literature and then identify some gaps and my own suspicions and insights- for whatever they’re worth. This episode’s transcription and 60+ citations are under the resources tab at www.daytonicuconsulting.com, so please check it out and do your own homework. Let me know your thoughts.

Let’s start with why and how do unplanned extubations happen?

Studies have stated that some of the following are risk factors for unplanned extubations:

1. Inadequate breathing tube stabilization
2. Patient restlessness and agitation (1,2)
3. Inadequate sedation (2,3)
4. Use of physical restraints (2)
5. Absence of clear policies and procedures related to weaning (2)
6. Factors related to nursing staff (inexperience, night shift, inadequate staffing) (1)
7. Use of Midazolam to decrease agitation and delirium (4)

 

So again, the research on unplanned extubations is very inconsistent and conflicting depending on the size and focus of the studies [5]. Risk factors such as less sedation and restraint use have only proven to be correlated but not causative [6]. Assuming these studies were done in “normal ICUs” that automatically sedated patients until their ventilator settings were lower or until they attempted awakening trials…. it then makes sense why less sedation and restraint use make the top of the list now that we understand delirium and the reality of awakening trials. These studies were not comparing automatic continuous sedation to allowing patients to wake up right after intubation. We need such a study.

What makes sense to me is that unplanned extubations happened at greater rates when sedation was lightened or weaned off and delirium and agitation were unmasked. Then restraints were more likely to be present as the delirium increased their risk of impulsive and risky behaviors such as unplanned extubations.

Of many studies on unplanned extubation, delirium is included in only a few select studies, but has shown significant correlation if not causation to the events [5, 6]. When I present at conferences, I have the audience raise their hands if they have had a patient self-extubate. Most hands usually raise. Then I ask them to keep their hands up if any of those events were with patients that were free of delirium. I have yet to see any hands stay raised with that final question.

Now I personally have seen a patient consciously self-extubate, but he was very terminal and did not want to wait the extra 2 days for his family to arrive at his bedside as his wife was insisting. That situation ethically should have been handled differently and his autonomy should have been more respected. Otherwise, the very few unplanned extubations that I’ve seen which were almost all self-extubations… were in the setting of delirium.

Unplanned extubations are very rare in the “Awake and Walking ICU” even with 3 mobility sessions a day which is usually walking, and patients are generally awake and sitting in the chair throughout much of the day.  They went over two years without any unplanned extubations before COVID hit- and that was with obviously very high glasscow coma scores, and very little sedation used.

So that’s where I personally struggle to just look at these abstracts, skip to the conclusion, and nod my head and say, “Ok, so, therefore, using too little sedation sets patients up for unplanned extubations. It is not safe to minimize sedation. More sedation, the more the tube stays in. The safer the patient is. Got it.” – That just doesn’t line up with everything else we’ve explored and learned here.

Some of these studies did not have the best methodology either. One study that did look at delirium in relation to unplanned extubations did not see a correlation. Turns out that the original publication only used a sample size of 50. Then when they doubled the sample size to 100… bingo- they saw a correlation between delirium and unplanned extubations(6). Yet such limited studies with poor conclusions can really lead us astray to believe that patients cannot be safely awake while intubated because that will increase risks of unplanned extubations.

Maybe because I’m clearly fixated on delirium… but it blows my mind that unplanned extubations would be conducted without evaluating for delirium. Perhaps because some of these were done before the CAM score was standardized and patients were likely too sedated to really be screened for delirium.

Some of the studies showed that agitation, restlessness, etc. increased risks of unplanned extubation but then didn’t dive deeper. Could it be that a lot of that agitation and restlessness were from delirium? What caused the delirium? Did we set them up for it? If the restlessness was from pain, couldn’t we ask or assess patients for pain? Instead, we are often exacerbating their delirium and making them less able to understand what the tube is and keep it safe.

I worry that only identifying “restlessness” and as a risk factor for unplanned extubation without digging into the root cause of it and helping us understand how to prevent it will lead us to conclude that we must sedate away restlessness. This perpetuates the culture of masking distress with sedation in the name of safety rather than assessing and treating the root cause and truly keeping patients safe.

One study done with a retrospective chart review did show that delirium made patients 11.6 times more likely to have an unplanned extubation and agitation made it 9 times more likely to occur(7). This resonates with my biased experiences that lead me to believe that keeping patients safe from delirium also helps keep their lines and tubes safe.

I saw in the “Awake and Walking COVID ICU” that the few unplanned extubations that broke that streak without events happened in the setting of delirium and almost all of them were after patients had been sedated while having to be proned and paralyzed.

We already know that midazolam use increases the risk of unplanned extubation(3)- likely because for every 1 mg there is a 7-8% increased risk of delirium (8). Increased delirium equals increased unplanned extubations. Still, I would love to see type, depth, and duration of sedation prior to unplanned extubations included in future studies.

Yet, we can also see in these studies that there are other elements that increase the risks of unplanned extubations. Lack of nursing experience, night shifts, poor weaning policies (like doing awakening trials at 5am without family or help available), inadequate staffing, etc. all create this perfect storm for unplanned extubations.

Obviously we do not want unplanned extubations to occur. We should be concerned about them. Yet, there is another vital part of the discussion that can really guide our level of fear of unplanned extubations: Re-intubations.

Why are some patients in absolute danger when they lose an endotracheal tube, some do ok on high flow for a while and then must be re-intubated, and others don’t have to be re-intubated at all? When you look at re-intubation rates following unplanned extubations, they are again extremely variable.

I imagine many experienced some level of tube dislodgement or even unplanned extubation with proning during COVID. That had to be extremely traumatic as most if not all of those patients were deeply sedated and paralyzed. They were not going to have any respiratory effort on top of extremely sick lungs and poor reserve and were at high risk of immediate death. Every time they required emergency bagging and re-intubation. THAT is the scenario burning in our minds when we imagine an unplanned extubation. Yet they’re not all like that.

I think we all appreciate that every patient is different. Diagnosis, acuity, reason for needing mechanical ventilation, level and point in acute respiratory failure, ventilator settings, and so on are all so different and impact whether or not a patient must be re-intubated after an unplanned extubation.

Obviously, if a patient is on a PEEP of 16 and 90%, they’re more likely to need to be re-intubated than someone that is on a PEEP 5 and 40%. Yet, some patients have lower ventilator settings and need to be re-intubated at higher rates or quicker than those that had higher ventilator settings. It is important to understand some important factors that can cause this to occur. A lot of it can depend on sedation, delirium, and diaphragm dysfunction. Remember- the respiratory system is not just the lungs but the brain and muscles as well.

So, if a patient has been deeply sedated for prolonged periods of time then there are a few reason why they are at high risk of being in big trouble if that tube is lost. Obviously number 1 is their level of consciousness. If sedation is being given at high doses and the tube is removed, their respiratory drive is suppressed, and they won’t be breathing. That is a huge emergency. They need to be bagged and likely reintubated right away.

If they have developed hypoactive delirium from that sedation even it if is off, then they are less likely to be able to protect their airway, hold their head up, mobilize and clear their secretions. They too are at high risk of needing to be reintubated even just for altered level of consciousness.

A huge factor that we fail to appreciate is that if they have been sedated and immobilized, then they are high risk of hypoventilation due to diaphragm dysfunction or even paralysis. We know that propofol is myotoxic and disrupts the GABA receptors and sodium channels of the muscles (9,10).

In rats, we have seen that propofol and midazolam are independent risk factors for diaphragm dysfunction even without mechanical ventilation (11). Though the ventilator does the work of the diaphragm for breathing, we still engage the diaphragm when sitting, standing, and walking on the ventilator. Yet when patients are immobile under sedation, the diaphragm and respiratory muscles are under severe attack from hyperinflammatory process during critical illness, absolute disuse, and the myotoxic sedatives. Then they no longer have the muscular strength to independently drop the diaphragm and inflate the lungs.

This is one of the main reasons so many COVID patients could not pass their breathing trials even once their lungs were mostly healed and ventilator settings were minimal. Their new neuromuscular condition of ICU acquired weakness developed in the ICU and usually from ICU care makes them dependent on the ventilator. Losing an endotracheal tube while the diaphragm is dysfunctional can be very dangerous and absolutely requires re-intubation. It’s like removing mechanical ventilation from a high spinal cord injury. They will not be able to breath.

This is a main reason why reintubations after unplanned extubations for cardiac surgery patients was 4% in one study- they likely had not been sedated and immobilized, and in the likely absence of a pulmonary process going on, they were able to breathe independently and not require intubation after an unplanned extubation (12).

Also, this ICU-acquired weakness puts them at high risk of re-intubation just for aspiration. Even if they can do the work of ventilation, if they are not strong enough to adequately cough, hold their heads up, protect their airways, swallow, etc…. then they are at high risk of aspirating and requiring re-intubation just for that.

So with that perspective, it then makes sense why the re-intubation rates were so much lower in the 2019 ABCDEF bundle study. As this study still involved automatic sedation and had such variable approaches to when and how to break and wean off sedation, they had 60% less restraints used and yet still had the same amount of unplanned extubations between the trial and control group. That alone is amazing and underappreciated. With less sedation there was less restraint us and no increase in self-extubations. Likely because there was a 25-50% decrease in delirium.

In the end, they found was that though the ABCDEF bundle group had the same amount of unplanned extubations, they had LESS re-intubations. This is likely because they had less sedation and more mobility- meaning they were more awake and stronger and able to fly when they accidentally lost a tube(13).

In episode 44, Kenneth Hurwitz shared his journey of being awake and mobile on the ventilator through the first 6 days of mechanical ventilation, then awake and prone for 2 days and sedated and paralyzed for 6 days. As soon as he could be supine, they did an awakening trial. Once they found he could oxygenate with movement, there was no longer a need for sedation. They stopped it and the delirium he had developed and suffered under sedation was unmasked. They immediately started to sit and stand him to treat the delirium and rehabilitate him as he had quickly lost significant muscle during that time of being sedated.

Four days after being supine then awake and mobile, in his delirium and isolation, Kenneth self-extubated. He was on around a PEEP of 10 and 60% before removing the tube. When the respiratory therapist walked in, he had the tube in his hand and when asked why he did it, he said right there in that moment, “I didn’t need it anymore.”

Even telling that story makes my heart race. The idea of someone self-extubating is still so stressful to me. Yet, imagine- he was right. Because he was free of sedation, mobile, and even sitting in the chair at the moment- he did not need to be re-intubated. He spent another day or so on high-flow nasal cannula and then went to the floor and straight home after that. (14)

So yes, he broke the long streak of years without unplanned extubations, yes it was stressful to have that event happen, and in a study it could be concluded that he self-extubated because of inadequate sedation… but would it really have been safer to have him deeply sedated? Had he been sedated just for being intubated, it would have cost him over 10 days more of deep sedation, he still would have been at high risk of unplanned extubation but would have certainly been reintubated in the same scenario. Turning sedation off once there was no longer an indication for it ultimately kept him safer despite his unplanned extubation.

An older study showed a significant difference between accidental extubations- like the kind that happen in sedated patients during bed baths and transportations- and self-extubations. They found all of the patients with accidental extubations had to be reintubated, but 37% of the patients that self-extubated did not have to be re-intubated. My suspicion is that this is tied to the fact that as patients that were awake and strong enough to pull out their own tubes, they were also able to breathe on their own. That same study also found that those reintubated patients were 14% more likely to develop a nosocomial pneumonia. (15)

Between multiple studies, there is a wide range of reintubation rates after unplanned extubation ranging from 45.8% to 79.6% (1,3,7,15). This seems to be as wide a spectrum as our sedation and mobility practices, but I am sure there are other factors that play into so much variation.  Nonetheless, the principle still stands. The less sedation used and the more mobility applied the less likely they are to be reintubated if an unplanned extubation occurs.

This is probably partially why a COVID study in China compared the rates between COVID patients and non-COVID patients and found that the unplanned extubation rates were the same but the reintubation rates were much higher in the COVID group. Perhaps the duration, type, and depth of sedation and then the paralytics and immobility played a key role in the failure of these unplanned extubations (58).

We know that there is a huge difference in outcomes between those that have to be re-intubated and those that do not. Those that need to be reintubated have a much higher mortality rate than those that did not have to be reintubated(16). This is likely for a number of reasons. Sicker patients usually need to be re-intubated. One study clearly showed that the higher the fi02 settings were the more likely they were to be reintubated. That makes sense.

Yet even for those patients who are out of severe critical illness but are stuck in the rut of ICU-acquired weakness and just too sedated, delirious, or weak to independently breath, reintubation can set them up for risks of aspiration, ventilator-associated pneumonia, and so on. Also, important to consider when looking at the studies is that because of our current culture, when patients are reintubated they are automatically re-sedated. I also wonder how often these patients are sedated even more deeply with the fresh fear of repeated unplanned extubation. This all keeps them on the ventilator longer and sets them up for higher risks of all the repercussions. So obviously they’re going to do much worse with a higher mortality.

We see that the self-extubations are likely less harmful. One study showed that self-extubation had a significantly lower mortality rate than the accidental extubations. I don’t want to make conclusions that go beyond the scope of the study, but I think it is fair to wonder if this is influenced by the likelihood that the patients that self-extubated has less depth or duration of sedation than those that lost their tubes while sedated (59).

So let’s zoom out on all of this. When it comes to sedating intubated patients, most decisions are fear-based rather than evidence-based. We are terrified of self-extubation. We should be concerned about them, but how dangerous are they and what really prevents them?

To summarize what I just shared, 63% of unplanned extubations are self-extubations which we can confidently suspect usually happen in the setting of delirium. Patients that do not need reintubation after an unplanned extubation are not likely to die and have minimal repercussions. Most reintubations are from accidental extubations rather than self-extubations. Despite the lesser sedation use and 60% less restraint use, the A2F study showed the same amount of unplanned extubations but a far lower rate of reintubation. Therefore, the ABCDEF bundle patients that lost a tube did much better and had a lower death rate. Ultimately, it is safer to avoid sedation- even and especially if an endotracheal tube is lost.

So if we’re worried about patient safety, we will care for them in a way that not only minimizes the risks of unplanned extubations, but increases their chances of being awake and strong enough to survive and even fly without the ventilator if that does happen.

So though self-extubations are safer than any other kind of unplanned extubation, we still don’t want them to happen. There are risks involved and we want them to be safe. Yet, does sedation keep them safer?

To do a true risk vs. benefit analysis before starting sedation, we must not only understand the risks of unplanned extubations, but also the risks of sedation and immobility and then decide whether or not it is worth it for that specific patient.  So if we’re caring about safety and risks, we’ll discuss as a team the reality that sedation and immobility:

Increase the risks of:

• Dying in the ICU or after the ICU [20, 21]
• Infection [22, 23]
• Pressure injuries [24]
• Blood clots [25]
• Delirium [26,27,28]
• ICU acquired weakness[29]
• More time on the ventilator [30]
• More time in the hospital [31]
• Tracheostomy [13]
• Discharge from hospital to rehabilitation center or nursing home[13]
• Post-ICU PTSD[32, 33]
• Post-ICU dementia (cognitive dysfunction) [34]
• Depression[35]
• Being readmitted to the hospital and ICU [36]
• Post-Intensive Care Syndrome [37]

 

Sedation decrease the chances of:

• Discharging home from the hospital [13]
• Being able to walk upon transfer from the ICU [38]
• Returning to work [39]
• Optimal quality of life [40]

 

Avoiding sedation and early mobility (ABCDEF Bundle) decrease the risks of:

• Death [41]
• Ventilator and hospital associated pneumonia [42]
• Central Line and catheter infections [43]
• Pressure injuries [44]
• Falls [45,46]
• Delirium [13]
• Aspiration Pneumonia [50]
• Constipation/ileus [51]
• Intubation [13]
• Re-intubation [13]
• Tracheostomy and PEG tube placements [52]
• Discharges to care facilities [13]
• Hospital and ICU readmissions [13]
• Diaphragm function [53]
• ICU Acquired Weakness [54]

 

We all need to be aware that by avoiding or minimizing sedation, we can improve the changes of:

• Successful extubation [13]
• Not being reintubated if an unplanned extubation does occur [13]
• Discharges from ICU [13]
• Discharges home [13]
• Survival [13]
• Functional independence after discharge [36]
• Quality of life [37]
• Lung aeration [55]
• Secretion clearance [55]

 

Yet, even if we don’t care about that huge bucket list of risks and repercussions and still only care about keeping the tube in, we must consider the reality of sedation and unplanned extubations. One study found that 71% of unplanned extubations in patients had continuous sedation, and most of the events occurred during weaning. It also found there was 22% more agitation in the intermittent sedation group than the no-sedation group all leading to more unplanned extubations (57). So, if we’re comparing the risks, we need to understand that starting sedation may keep the tube in for now, but will still set them up for more and far more dangerous unplanned extubations later.

When it comes to risks of unplanned extubation during mobility, we know that is extremely rare- far less than 1% of activity sessions have had an adverse event such as losing an endotracheal tube (65). Again, if it does happen- aren’t they likely safer to lose a tube while walking than while they’re mostly sedated, delirious, and weak in bed?

We also know that many accidental extubations occur during cares such as bed baths and repositioning(60,61,62,63,64). Should we then fear and avoid those cares like we do with mobility?

Preventing unplanned extubations goes far beyond the myths that “the more sedation and the less we move patients the more we protect patients from the occurrence and harm of unplanned extubations”. Ensuring endotracheal tubes stay in place until it is time for extubation is facilitated by a bigger picture.

Safe staffing ratios are an absolute must. Nursing ratios should NEVER be 3:1 or more. For SO many reasons, but obviously for the logistics of keeping a close eye on intubated patients. The original “Awake and Walking ICU” has a 2:1 nursing ratios and 4-6:1 RT ratio. Last week, I was doing a multidisciplinary Q&A webinar with a team that is working towards becoming an “Awake and Walking ICU” and members of the “Awake and Walking ICU”. One of the big questions asked was, “What are your staffing ratios?” – turns out the inquiring team had better staffing and more resources than the “Awake and Walking ICU”. – so how do they go years without unplanned extubations? Walk most patients 3 times a day? – I think a lot of it comes down to working smarter, not harder.

I cannot emphasize enough the importance of having process of care that minimizes delirium. Hopefully it makes sense to everyone how different the risks are to have patients come out of days to weeks of sedation and be totally delirious and weak vs. patients that are awake, sitting in a chair, and writing on a board, “Be careful of my tube”.

In general, the stress and work required to keep such a patient safe are completely different than what you experience when taking off days to weeks of sedation and unmasking delirium and a hot mess rodeo.

Check out episode 76 and an upcoming episode to hear travel nurses talk about the contrast in workload and why they find the “Awake and Walking ICU” approach safer and easier.

Nonetheless, delirium or encephalopathy aren’t always preventable. Sedating a patient just to keep a tube is not ideal and is not a long-term approach to improving their chances of survival. Often we’re exchanging keeping a tube in place for the moment for a tracheostomy, all the sequelae, or even ultimately death. So… then what?

In those exceptional cases… we need teamwork. In the “Awake and Walking ICU”, there a prioritization of sitters in the ICU for those situations. There is no expectation of deeply sedating them. If sedation is used, it is to bring a RASS of 3 or 4 down to 0 or 1. Everyone is aware who is delirious, who needs extra eyes on them, and who needs a sitter. They call family in to help. Despite having a detox unit down the hall, lots of septic shock, liver failure, and so on… unplanned extubations are rare.

I wish systems understood that sitters are a HUGE return on investment. If having a sitter helps a team avoid sedation on a delirious patient and therefore be able to keep the endotracheal tube in place while truly treating delirium duration and therefore save days to weeks on the ventilator and weeks to months in rehab… they are worth their weight in gold!! Giving the ICU top priority for sitters will prevent and shorten delirium and ICU acquired weakness and decrease the need for sitters on the step-down units and floors.

We also need a safe culture for nurses. If unplanned extubations do happen, the culture must be to protect the nurse. The environment and circumstances are assessed to identify what went wrong and how to prevent repeats. For example, when I was a newer nurse on the unit, I had a patient self-extubate during a night shift. The patient was delirious and I grabbed a nurse I didn’t know to help me boost the patient up. I didn’t realize that this was a floating nurse from the medical floor with little to no experience tying restraints. I didn’t double-check the restraints and the patient got to his tube. It was so long ago, I don’t recall whether or not he had to be re-intubated, but he did end up ok.

I didn’t get in trouble. I wasn’t made to feel bad or take all the blame, though I still feel accountable for that incident. We discussed the scenario and the reality was that we shouldn’t have had a nurse in the unit that was not ICU trained. Or at least I should have been made aware about their skillset and the patients that they are allowed to care for such as boarders. – This is how we create a safe workplace environment. I was told from day one: “We all make mistakes, but we learn from our mistakes”.

After COVID hit, there was another unplanned extubation after Kenneth Hurwitz. We had switched to new beds and we had an intubated patient with sepsis and delirium get to her tube. The nurse didn’t get in trouble. We didn’t turn around and sedate that patient or other patients. We assessed the situation.

Turns out, the hooks for the restraints on the new beds were further away and required longer restraints than we were using. We ordered new restraints with longer ties. THAT was the answer- in addition to recognizing that the isolation during COVID and tighter staffing ratios contributed to that situation. Yet we learned from it and moved on. That patient walked out of the ICU. We kept her safe in the short term and even for the long-term.

Dr. Wes Ely tells a story about being with an ICU team in Korea. A nurse expressed the normal concern and said, “What if they pull their tube out?” – and another nurse jumped in and said, “But what if they never walk again??” — So much of this comes down to perspective.

A podcast listener and hardcore revolutionist told me of her patient’s self-extubation. The patient was on higher ventilator settings, he wasn’t delirious, he was communicating on the board, but he had some baseline psychopathology that made her question his trustworthiness. She had another patient to tend to and asked the charge nurse for a sitter or for help. She was told, “Just sedate him!” Well… she was in a tough and lonely spot. She saw this big picture, she has taught herself why and how to keep patients awake and mobile even in an environment that doesn’t usually practice that way or support her in it… but she recognized immediate risks and needed support. The patient promised he wouldn’t mess with his tube… but as seemed to be his nature- he changed his mind. He did have to be re-intubated but was ok.

The nurse management was really upset with this nurse. They pulled her into the manager’s office ready to let her have it… when the attending came in, made a scene, and said, “This nurse is practicing better evidence-based medicine than the rest of us!! If she gets any heat for this, you’ll have me to answer to.” – THAT is the leadership we need. Our teams need to be united in the reality of sedation and immobility and have the same understanding of how to save lives in the ICU.

In episode 91, Dr. Thomas Strom from an “Awake and Walking ICU” in Denmark where their nursing ratios are 1:1 for intubated patients said that if they go too long without self-extubations, they worry! They scour their charts and assess their sedation practices to make sure they’re not using too much sedation. They recognize that perhaps sedating patients is more dangerous than self-extubations.

By now, we know that sedation rarely makes patients safer. A truly safe environment takes the entire team. Before COVID hit, the NP group in the “Awake and Walking ICU” had established “safety rounds”. The NP on each shift would go with the charge nurse to each patient’s room and have a quick check-in with the nurse. We would have a sheet with a list of categories that would help us identify the specific risks and levels of risks of the patient.

We identified current problems as well as those that could develop- things like, “delirium, falls, line/tube removal, pressure injury, ICU acquired weakness, hypoxia, delayed intubation,” etc. Each risk had a card with an image reflecting that risk and it came in 2 different colors to identify the level of risk. For example, if a patient was on 100% HFNC and at risk of needing to be intubated soon, they would have a red “delayed intubation” and red “hypoxia” card so that everyone knew walking in that this patient had to have their HFNC on or if something happened, we needed to be prepared to intubate. Or if a patient was intubated but had delirium- we would have cards to identify that so anyone walking in would know if they had their hands free- that they were not trustworthy.

It was an opportunity to collaborate and critically think and proactively plan with the nurses. We anticipated problems and acted before they happened. The better we got at it, the quicker it became, and the more the team liked them. They felt supported, heard, and had opportunities to learn.  … Then COVID hit and it all stopped. Yet that is the kind of culture that keeps patients safe and teams united.

Another part of unplanned extubations are the events that happen even when a patient doesn’t lift a finger. They happen during bed baths, turns, etc. More training and education about tube securement methods and devices may be needed. Maybe we need more training on how to move patients from the bed to the stretcher, protecting tubes during pronation, or safely doing bed baths.

That doesn’t mean that we stop doing those tasks because unplanned extubation occurred during them. Same with mobility. Ironically, our community is terrified of them happening during mobility- but that risk and the event rates are FAR LOWER than bed baths. That has been repeatedly proven in the literature and I personally have never seen a tube lost during mobility. When we mobilize patients, we prevent and treat delirium and decrease their risk of self-extubation. When we keep them strong, we make them more likely to survive and even avoid re-intubation if unplanned extubation does occur.

In summary, sedation and immobility come with huge risks and a high price. We need to create safe environments in which patients are safe from iatrogenic harm from sedation and immobility. We also do need to be aware and on guard to protect patients from unplanned and self extubations- but proper delirium prevention will make that more feasible for everyone involved.

As a podcast listener just wrote me, “I’ve learned that when we don’t sedate patients so heavily in the beginning you don’t really have to worry about MOST patients trying to self-extubate. They are in their right mind and can be in loose wrist restraints without pulling their tube.” – I would also add that often, they can be free of restraints and even dictate that they want restraints on at night as a reminder and precaution.

In conclusion, think of it this way:

A study in 2016 evaluted the impact of all the bundles- DVT, VAP, HAPI, lung-protective strategies, foley and central line bundles, etc in 118 hospitals. They measured the difference in outcomes of great compliance with all the bundles at once. Then they compared it to the impact on outcomes of the ABCDEF bundle and found that the A2F bundle improved outcomes more than all of the other bundles combined. This isn’t to say that the other bundles aren’t important, but that the A2F bundle is just as if not even MORE vital.

Certainly, self-extubations can be life or death. We more easily prevent them and make them less deadly with true mastery of the ABCDEF bundle. Give it a try. Let your patients wake up after intubation when they don’t actually need sedation. Let them acclimate. Let them understand and adjust to the tube. Watch them work with you in their cares, tasks, and especially protection of their lifeline. You’ll do them and yourself a life-saving favor.

 

 

References:

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