Unplanned extubations in general intensive care unit: A nine-year retrospective analysis

Reintubation during COVID-19 pandemic: a simple self-made guiding device facilitates reintubation and minimizes transmission

Consensus guidelines to protect airway managers during COVID-19 were developed to encourage safe, accurate and swift performance in intubation and extubation, but reintubation was not considered. With the massive surge of patients requiring mechanical ventilation in this COVID-19 pandemic, great incidence of difficult airways may necessitate reintubation. Equipments could be used now in extubation and reintubation are either too expensive and time-consuming in decontamination, or have not gained wide acceptance. Here, we adapted an extubation device from an intubating stylet, which is provided as accessory of endotracheal tube. Such stylet could provide safe access for expediting reintubation both during and after the COVID-19 pandemic, which is inexpensive, single-use, readily available, straightforward to handle, and well-tolerated, thereby benefiting both the patients and healthcare providers.

Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients

OBJECTIVE

To investigate short and long-term complications due to standard (≤24 hours) and extended (>24 hours) prone position in COVID-19 patients.

METHODS

Retrospective cohort study conducted in an Italian general intensive care unit. We enrolled patients on invasive mechanical ventilation and treated with prone positioning. We recorded short term complications from the data chart and long-term complications from the scheduled follow-up visit, three months after intensive care discharge.

RESULTS

A total of 96 patients were included in the study. Median time for each prone positioning cycle (302 cycles) was equal to 18 (16-32) hours. In 37 (38%) patients at least one cycle of extended pronation was implemented. Patients with at least one pressure sore due to prone position were 38 (40%). Patients with pressure sores showed a statistically significative difference in intensive care length of stay, mechanical ventilation days, numbers of prone position cycles, total time spent in prone position and the use of extended prone position, compared to patients without pressure sores. All lesions were low grade. Cheekbones (18%) and chin (10%) were the most affected sites. Follow-up visit, scheduled three months after intensive care discharge, was possible in 58 patients. All patients were able to have all 12 muscle groups examined using theMedical Research Council scale examination. No patient reported sensory loss or presence of neuropathic pain for upper limbs.

CONCLUSIONS

Extended prone position is feasible and might reduce the workload on healthcare workers without significant increase of major prone position related complications.

Anesthesia, Sedation, and Unplanned Extubation of Tracheal Intubation in Children with Severe Pneumonia

We randomly divided 200 children with severe pneumonia who met the indications for tracheal intubation into 2 groups in this prospective study. One group that received dexmedetomidine for sedation was recorded as the dexmedetomidine group (n = 100), and the group that received midazolam for sedation was recorded as the midazolam group (n = 100). We compared the anesthesia sedation scores, time to fall asleep, time to wake up from anesthesia, related hemodynamic parameters, and adverse reactions between the two groups of children. The failure mode and effect analysis method (FMEA) was also used to investigate the causes of unplanned extubation (UEX) of tracheal intubation in 32 children with severe pneumonia. Our conclusion is as follows: (1) Compared with midazolam, the comprehensive effect of dexmedetomidine on children with severe pneumonia undergoing tracheal intubation for anesthesia and sedation is better, it can effectively shorten the anesthesia induction time and the recovery time after stopping the drug, and there are few adverse reactions, which is worthy of application and promotion. (2) UEX is an important risk factor in the monitoring and nursing of children with severe pneumonia tracheal intubation, and the nursing method of PDCA cycle management is particularly important for them.

Multidisciplinary team approach in critically ill COVID-19 patients reduced pronation-related complications rate: A retrospective cohort study

Background

In the pandemic scenario, critically ill COVID-19 patients' management presented an increased workload for Intensive Care Unit (ICU) nursing staff, particularly during pronation maneuvers, with high risk of complications. In this contest, some authors described an increase in complications incidence after pronation. An ICU Pronation Team (IPT) was implemented to support this maneuver.

Material and methods

Retrospective analysis was conducted on consecutive critically ill COVID-19 patients in COVID-19 Center in southern Switzerland, between March and April 2020. Aim of the study was to determine rates and characteristics of pronation-related complications managed by IPT according to standard protocols.

Results

Forty-two patients undergoing mechanical ventilation (MV) were enrolled; 296 prone/supine positioning were performed, with 3.52 cycles/patient. All patients were equipped with arterial line, central venous catheter, urinary catheter, 28 (66%) endotracheal tube, 8 (19%), tracheostomy, 6 (14%) dialysis catheter, 3 (7%) abdominal drainage and 8 (19%) femoral thermodilution catheter; mean BMI was 28.3 kg/m². One (0.3%) major complication was observed, while fourteen (33.3%) patients developed minor complications (pressure injuries). ICU length-of-stay and MV days correlated with both incidence (p = 0.029 and p = 0.015 respectively) and number (p = 0.001 and p = 0.001 respectively) of pressure sores (n = 27). Propensity matching score analysis did not show any protective factor of pronation regarding pressure injuries (p = 0.448). No other significant correlation was found.

Conclusion

Multidisciplinary healthcare professional management can reduce most severe complication related to pronation in critical care setting. Rather than from pronation, the persistent high rate of minor complications appeared to be related to disease severity.

Development and Validation of Unplanned Extubation Prediction Models Using Intensive Care Unit Data: Retrospective, Comparative, Machine Learning Study

Background

Patient safety in the intensive care unit (ICU) is one of the most critical issues, and unplanned extubation (UE) is considered the most adverse event for patient safety. Prevention and early detection of such an event is an essential but difficult component of quality care.

Objective

This study aimed to develop and validate prediction models for UE in ICU patients using machine learning.

Methods

This study was conducted in an academic tertiary hospital in Seoul, Republic of Korea. The hospital had approximately 2000 inpatient beds and 120 ICU beds. As of January 2019, the hospital had approximately 9000 outpatients on a daily basis. The number of annual ICU admissions was approximately 10,000. We conducted a retrospective study between January 1, 2010, and December 31, 2018. A total of 6914 extubation cases were included. We developed a UE prediction model using machine learning algorithms, which included random forest (RF), logistic regression (LR), artificial neural network (ANN), and support vector machine (SVM). For evaluating the model’s performance, we used the area under the receiver operating characteristic curve (AUROC). The sensitivity, specificity, positive predictive value, negative predictive value, and F1 score were also determined for each model. For performance evaluation, we also used a calibration curve, the Brier score, and the integrated calibration index (ICI) to compare different models. The potential clinical usefulness of the best model at the best threshold was assessed through a net benefit approach using a decision curve.

Results

Among the 6914 extubation cases, 248 underwent UE. In the UE group, there were more males than females, higher use of physical restraints, and fewer surgeries. The incidence of UE was higher during the night shift as compared to the planned extubation group. The rate of reintubation within 24 hours and hospital mortality were higher in the UE group. The UE prediction algorithm was developed, and the AUROC for RF was 0.787, for LR was 0.762, for ANN was 0.763, and for SVM was 0.740.

Conclusions

We successfully developed and validated machine learning–based prediction models to predict UE in ICU patients using electronic health record data. The best AUROC was 0.787 and the sensitivity was 0.949, which was obtained using the RF algorithm. The RF model was well-calibrated, and the Brier score and ICI were 0.129 and 0.048, respectively. The proposed prediction model uses widely available variables to limit the additional workload on the clinician. Further, this evaluation suggests that the model holds potential for clinical usefulness.

Frequency and Analysis of Unplanned Extubation in Coronavirus Disease 2019 Patients

Objectives:

To determine if patients with coronavirus disease 2019 had a greater number of unplanned extubations resulting in reintubations than in patients without coronavirus disease 2019.

Design:

Retrospective cohort study comparing the frequency of unplanned extubations resulting in reintubations in a group of coronavirus disease 2019 patients to a historical (noncoronavirus disease 2019) control group.

Setting:

This study was conducted at Henry Ford Hospital, an academic medical center in Detroit, MI. The historical noncoronavirus disease 2019 patients were treated in the 68 bed medical ICU. The coronavirus disease 2019 patients were treated in the coronavirus disease ICU, which included the 68 medical ICU beds, 18 neuro-ICU beds, 32 surgical ICU beds, and 40 cardiovascular ICU beds, as the medical ICU was expanded to these units at the peak of the pandemic in Detroit, MI.

Patients:

The coronavirus disease 2019 cohort included patients diagnosed with coronavirus disease 2019 who were intubated for respiratory failure from March 12, 2020, to April 13, 2020. The historic control (noncoronavirus disease 2019) group consisted of patients who were admitted to the medical ICU in the year spanning from November 1, 2018 to October 31, 2019, with a need for mechanical ventilation that was not related to surgery or a neurologic reason.

Interventions:

None.

Measurements and Main Results:

To identify how many patients in each cohort had unplanned extubations, an electronic medical records query for patients with two intubations within 30 days was performed, in addition to a review of our institutional quality and safety database of reported self-extubations. Medical charts were manually reviewed by board-certified anesthesiologists to confirm each event was an unplanned extubation followed by a reintubation within 24 hours. There was a significantly greater incidence of unplanned extubations resulting in reintubation events in the coronavirus disease 2019 cohort than in the noncoronavirus disease 2019 cohort (coronavirus disease 2019 cohort: 167 total admissions with 22 events—13.2%; noncoronavirus disease 2019 cohort: 326 total admissions with 14 events—4.3%; p < 0.001). When the rate of unplanned extubations was expressed per 100 intubated days, there was not a significant difference between the groups (0.88 and 0.57, respectively; p = 0.269).

Conclusions:

Coronavirus disease 2019 patients have a higher incidence of unplanned extubation that requires reintubation than noncoronavirus disease 2019 patients. Further study is necessary to evaluate the variables that contribute to this higher incidence and clinical strategies that can reduce it.

Insertion of four different types of supraglottic airway devices by emergency nurses. A mannequin-based simulation study

BACKGROUND

During medical emergencies, one of the main steps to improve patient outcomes is to achieve airway management. Orotracheal intubation is highly effective for advanced airway management, but it requires experienced health professionals. The use of a supraglottic airway device (SAD) is an acceptable alternative.

AIM

To assess which of the four considered SADs takes the shortest time and the lowest number of attempts to be correctly placed. The secondary aim was to evaluate the influence of some characteristics of the study population on time taken and number of attempts required.

METHODS

A crossover trial was conducted at the Advanced Medical Simulation Center of the University of Perugia (Italy) between June and September 2017. Eighty-three nurses were enrolled in the study. Each participant was asked to place four different SADs in a manikin: Laryngeal Tube Suction-D (LTS-D), i-gel™, Ambu® Laryngeal Mask AuraGain™ and LMA® Protector™ Cuff Pilot™.

RESULTS

The median insertion time for the different devices was: 8.0 seconds (s) for LTS-D, 6.0 s for i-gel, 5.4 s for AuraGain, 5.8 s for LMA Protector (p<0.05); the median number of insertion attempts was: 2 for LTS-D, 1 for i-gel, AuraGain and LMA Protector (p<0.05). There was no significant relationship between insertion time and attempts required and the participants' working experience, training, or knowledge of the devices.

CONCLUSION

With the exception of LTS-D, which had the worst performance, there was a high degree of homogeneity between the studied SADs in terms of time and attempts required to achieve correct placement.