Episode #88 Unplanned Extubation Part 1: Incidence and Risk Factors

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are ready to start discussing some of the outstanding articles from the newest edition of the APSF Newsletter from February 2022. The first article that we will discuss is…

Before we dive into the episode today, we’d like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Fresenius Kabi – we wouldn’t be able to do all that we do without you!”

Are you ready? We are excited to crack open the February 2022 APSF Newsletter to talk about a big threat to anesthesia patient safety. Since anesthesia professionals are experts in airway management, unplanned extubation is a critical event which may have a big impact on patient safety. One of the authors of our featured article, Lauren Berkow, contributed to the show today and I am going to let her introduce herself and the article now.

[Berkow] Hi, my name is Lauren Berkow and I’m a professor of Anesthesiology at University of Florida in Gainesville, FL and the co-author of the article, “Unplanned Extubation in the Perioperative Environment.”

[Bechtel] Berkow is also the immediate past president of the Society for Airway Management and a board member of the Airway Safety Movement and the co-chair of the Patient Safety Movement Foundation’s Unplanned Extubation Workgroup. Her co-author is Arthur Kanowitz who is the founder and Board member of the Airway Safety Movement and the chair of the Patient Safety Movement Foundations Airway Safety Workgroup.

To follow along with us, head over to APSF.org and click on the Newsletter heading. For the next few months, this will be our current issue, so go ahead and click on the first one down, Current Issue. Then, scroll down and the 6^th article is our featured article today, “Unplanned Extubation in the Perioperative Environment.” I will include a link in the show notes as well.

Before we get into the article, we are going to hear from Berkow again. I asked her, “Why did you write this article?” Let’s take a listen to what she had to say.

[Berkow] Well, many years ago my co-author gave a presentation at one of our Society for Airway Management annual meetings about unplanned extubation and really opened my eyes to the problem. As a result, I started the SAM special project committee on unplanned extubation and asked him to join me as my co-chair and we’ve been trying to address the problem ever since.

[Bechtel] Thank you to Berkow for helping to kick off the show today and to both authors for your commitment to addressing the problem of unplanned extubation. And with that, let’s get into the article.

Anesthesia professionals are no strangers to airway management which may include intubation followed by extubation after some time depending on the indication, case, and patient. Keeping patients safe during extubation involves careful and controlled management at the appropriate time. It is a controlled procedure that may occur in the operating theatre, critical care unit, or emergency department and even in a controlled environment, the risk of complications following planned extubation is about 12%. The flip side is an unplanned extubation which is a threat to patient safety since it is not done in a safe and controlled manner at the expected time. It is a complication that may occur anywhere there is an intubated patient including during patient transport and procedural areas and may lead to increased morbidity and mortality. The Society for Airway Management and the Patient Safety Movement Foundation strive to increase education about unplanned extubation events and how to prevent this complication.

Have you ever witnessed and taken care of a patient following an unplanned extubation? This may occur due to the following:

• Self-extubation when the patient removes the tube by pulling on it
• Or Accidental extubation when the tube is removed following external force from patient movement or nursing care

The authors highlight that difficult intubation is a topic that is frequently addressed in the literature, but the same is not true about unplanned extubation and the related complications. In fact, the incidence of unplanned extubation may be higher since this complication may not be tracked and is likely under-reported.

Let’s take a closer look at the incidence and risk factors. There is a wide range reported in the literature, but it will likely come as no surprise that the median incidence of unplanned extubation is higher in the neonatal up to about 18% than in the adult population at about 7%. Keep in mind that this data is from studies in the ICU. This is a big threat to patient safety since it is the fourth highest reported adverse event in the neonatal ICU. Most recently, the incidence of unplanned extubation is higher at 13.2% in patients with COVID-19 compared to patients who did not have Covid-19 at 4.3%. This may be due to the challenges with securing the tube during prone positioning to improve oxygenation and ventilation in patients with COVID-19 pneumonia.

What about unplanned extubation in the Operating Room? You may have noticed that I did not mention the incidence of unplanned extubation in the operating room. At this time, it is unknown, but what we do know is that it is uncommon especially since intubated patients are under general anesthesia, often with muscle relaxation. During emergence, self-extubation may occur with a risk of vocal cord injury from the inflated endotracheal tube cuff, but reintubation may not be necessary at this time. Another important consideration is accidental extubation during the surgery in the OR which may occur during patient positioning, when the patient is in the prone position, when the airway is 180 degrees away from the anesthesia machine and anesthesia professional, and during surgeries on the head and neck. When the anesthesia professional is located away from the patient’s airway or cannot visualize the airway, there is a risk for delayed recognition of an accidental extubation leading to increased morbidity and mortality. Don’t let your guard down when you are transporting the patient since an accidental extubation may occur when moving the patient to the stretcher or during transport to the ICU.

Why does unplanned extubation occur more often in the ICU? This may be due to less use of muscle relaxation, use of sedation and not general anesthesia, higher patient to provider ratio, and frequent changes in position or tube manipulation. Unlike the OR, self-extubation is more common than accidental extubation in the ICU.

Check out table 1 in the article for risk factors for unplanned extubation. We are going to review them now. Get your pencils ready!

• Patient movement
• Manipulation of the endotracheal tube
• Inadequate sedation
• Inadequate securing of the endotracheal tube
• Lack of physical restraints
• Restlessness or agitation
• Delirium or Confusion
• Prone positioning
• Lack of clear vent weaning policies and procedures
• Lack of plan for extubation
• In adequate staffing

Now, let’s turn our attention to complications related to unplanned extubation. This is a big threat to patient safety since airway-related complications during emergence and extubation may be up to 30% and there is an even greater risk for airway complications outside of the operating room and in uncontrolled or emergency situations. Complications that may occur immediately after an unplanned extubation include the following:

• Vocal cord injury
• Tracheal damage
• Hypoxemia
• Hemodynamic instability
• Respiratory failure
• Brain Damage
• Cardiac Arrest
• Death

Once an unplanned extubation has occurred, proceeding with emergent re-intubation may not be a simple and straightforward procedure due to hemodynamic changes and airway edema or trauma. An easy airway may become a difficult or impossible airway. Depending on the patient positioning and the surgical procedure, it may be difficult to even access the airway leading to worsening oxygenation and ventilation and hemodynamic changes. Re-intubation is a common complication following an unplanned extubation with a incidence of almost 90% in studies with ICU patients. Keep in mind that re-intubation is more likely to be needed following accidental extubation compared to self-extubation. Other important complications include the risk of ventilator-associated pneumonia which increases from about 13% to about 30% following unplanned extubation as well as increased ICU and hospital length of stay.

We have seen that unplanned extubation has a high cost in terms of risks and complication for patients. There is also a significant cost burden associated with these events. From the literature related to ICU care and complications related to unplanned extubation, the overall yearly cost burden in the United States is about 5 billion dollars annually. Narrowing our focus down to a single unplanned extubation, the burden is an additional $41,000 to the average ICU cost (which is about $59,000) leading to a total ICU stay bill just over $100,000. There is a real call to action to keep patients safe and in doing so prevent additional healthcare costs.

Now, that we have reviewed the scope of the problem, let’s look at how we can prevent unplanned extubation events. First, we need to recognize that this is a problem based upon data and we need more data to continue to evaluate unplanned extubation events and rates as well as risk factors and complications. The authors include an example of an Extubation Classification Tool which would go a long way towards improved tracking and reporting of unplanned extubation events. Do you have an extubation classification tool at your institution? Do you know how many unplanned extubation events occur in your operating rooms and ICUs? Take a look at Table 2 in the article and we will discuss the tool now. It includes a chart with Extubation classification along the Y-axis including planned extubation as well as unplanned extubation broken down into self-extubation, accidental extubation, device malfunction, and presumed internal dislodgement. The next column reveals who removed the endotracheal tube the provider or the patient or unknown. The next three columns answer the following questions related to when the endotracheal tube was removed: Was readiness for safe removal of endotracheal tube determined? Was removal of endotracheal tube intentional? And was removal of endotracheal tube controlled with the balloon deflated prior to removal?

Let us know how you are tracking unplanned extubation events at your institution and we hope that you will tube in next week to find out more about preventing this event and keeping intubated patients safe until they are ready for a controlled and planned extubation. Plus, we will hear from Berkow again!

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

We are looking forward to discussing articles from the current issue of the APSF Newsletter from February 2022 on upcoming shows. Plus, you could be an APSF Newsletter author too. The APSF Newsletter is the official journal of the Anesthesia Patient Safety Foundation with an audience that includes anesthesia professionals, perioperative providers, key industry representatives, and risk managers. The next deadlines is right around the corner so mark your calendars for March 15^th for the June issue. Some of the types of articles include case reports, Question and Answer, Letter to the Editor, Rapid Response as well as invited conference reports, editorials, and reviews all with a focus on anesthesia related perioperative patient safety issues. For more information, head over to APSF.org and click on the Newsletter heading. The last one down is guide for authors and I will include a link in the show notes as well. Plus, make sure that you click on the Subscribe via email heading as well and sign up to be on the APSF Newsletter email list so that you can get expedited access by email to our current APSF Newsletter issue.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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