Darren KlugmanJohn T. BergerMichael C. SpaederAmy WrightWilliam PastorDavid C. Stockwell

Acute harm: unplannedextubations andcardiopulmonary resuscitationin children and neonates

Accepted: 9 April 2013Published online: 1 May 2013� Springer-Verlag Berlin Heidelberg andESICM 2013

All work pertinent to this research wasconducted at the Children’s NationalMedical Center, Washington, DC, USA.

Dear Editor,Invasive mechanical ventilation is acommon therapy used for childrenand infants in the intensive care unit(ICU). The impact of unplannedextubation (UE) on morbidity andmortality in adults is well described[1, 2]. There remains a paucity of datarelated to the cardiovascular morbid-ity associated with UE events inchildren.

Following review and approval bythe institutional review board inaccordance and compliance withinternational ethics standards, weperformed a retrospective databasereview of all UE events in patientsadmitted to the neonatal, pediatric orcardiac ICU at our institution betweenJuly 2011 and December 2012. UEwas defined as the removal of anendotracheal tube in a mechanicallyventilated patient which was notdirected or ordered by a licencedindependent practitioner. Cardiovas-cular collapse was defined as the needfor cardiopulmonary resuscitation(e.g., external chest compressions) orcirculatory dysfunction immediately

following the UE event. Patients withtracheostomies were excluded fromour analysis. Preliminary data werepresented at the Pediatric AcademicSocieties’ and Asian Society forPediatric Research Joint Meeting inDenver, Colorado in 2011 [3].

There were 119 UE eventsinvolving 95 unique patients, and theUE rate (events/100 ventilator days)was 0.5. Cardiovascular collapseoccurred in 24 events (20 %), ofwhich 20 involved initiation of car-diopulmonary resuscitation. Fourevents were characterized by circu-latory dysfunction requiringimmediate re-intubation without ini-tiation of cardiopulmonaryresuscitation. There was no immedi-ate mortality associated with theseevents. We compared UE eventcharacteristics stratified by presenceor absence of cardiovascular collapse(Table 1).

Immediate re-intubation was per-formed in 75 (63 %) events and wasmore likely in patients with cardio-vascular collapse (p = 0.01).Cardiovascular collapse was morelikely in younger patients(p = 0.048).

It has been recognized for sometime that UE carries with it signif-icant morbidity increasing the riskof nosocomial infection and lengthof mechanical ventilation and ICUstay [1]. This is the first study thatwe are aware of that assesses thefrequency of cardiovascularmorbidity associated with UE inchildren.

While much of the cardiovascularmorbidity occurred in our neonatalpopulation, our data suggest thatunplanned extubations in critically illchildren and neonates can lead topreviously unrecognized morbidity.Despite recent advances in cardio-pulmonary resuscitation andextracorporeal membrane oxygena-tion, in-hospital cardiac arrestportends poor outcomes with sur-vival to discharge rates hoveringaround 25 % [4]. Our study is lim-ited by the lack of long-term follow-up data to assess the impact of UEon mortality. However, our data dosuggest there is potential forincreased mortality associated withUE events.

In conclusion, the frequency ofcardiovascular morbidity in children

Table 1 Unplanned extubation event characteristics stratified by presence or absence ofcardiovascular collapse

Event characteristics CV collapse(n = 24), no. (%)

No CV collapse(n = 95), no. (%)

p value

Age (days) 49 (IQR 20–86) 67 (IQR 29–24 months) 0.048Intensive care unit 0.08CICU 4 (14) 10 (11)NICU 18 (75) 56 (59)PICU 2 (7) 29 (31)

Primary diagnosis 0.17CHD 4 (17) 11 (12)Neurological 0 10 (11)Prematurity 13 (54) 33 (35)Respiratory infection 2 (8) 20 (21)Other 5 (21) 21 (21)

Pre-UE ventilator days 6 (IQR 1–13) 4 (IQR 1–11) 0.90Ventilator weaning phase 4 (17) 29 (31) 0.30Patient receiving sedation 15 (63) 59 (62) 0.81Patient restrained 3 (13) 27 (28) 0.18Immediate re-intubation 21 (88) 54 (57) 0.01

CV cardiovascular, IQR interquartile range, NICU neonatal intensive care unit, PICUpediatric intensive care unit, CICU cardiac intensive care unit, UE unplanned extubation

Intensive Care Med (2013) 39:1333–1334DOI 10.1007/s00134-013-2932-x CORRESPONDENCE

with UE events is high. Previouslypublished benchmark data for pedi-atric UEs might not take into accountthe potential serious consequences ofthese events [5]. Efforts to decreaserates of UE are paramount. Our datademonstrate important morbidityassociated with pediatric and neonatalUEs which we believe supportincluding UEs in the discussion ofpreventable harm events.

Conflicts of interest On behalf of allauthors, the corresponding author statesthere is no conflict of interest.

References

1. de Lassence A, Alberti C, Azoulay Eet al (2002) Impact of unplannedextubation and reintubation afterweaning on nosocomial pneumonia riskin the intensive care unit: a prospectivemulticenter study. Anesthesiology97:148–156

2. Krinsley JS, Barone JE (2005) The driveto survive: unplanned extubation in theICU. Chest 128:560–566

3. 3. Klugman D, Berger JT, Galiote J,Stockwell DC (2011) Impact ofunplanned extubations in a children’shospital. E-PAS:752011

4. Topjian AA, Berg RA, Nadkarni VM(2008) Pediatric cardiopulmonaryresuscitation: advances in science,techniques and outcomes. Pediatrics122:1086–1098

5. da Silva PS, de Aguiar VE, Neto HM,de Carvalho WB (2008) Unplannedextubation in a pediatric intensive careunit: impact of a quality improvementprogramme. Anaesthesia 63:1209–1216

D. Klugman ()) � J. T. Berger �M. C. Spaeder � D. C. StockwellDivision of Critical Care Medicine,Children’s National Medical Center,111 Michigan Avenue, NW,Washington, DC 20010, USAe-mail: dklugman@childrensnational.orgTel.: ?1-202-4765321Fax: ?1-202-4765868

D. Klugman � J. T. BergerDivision of Cardiology,Children’s National Medical Center,Washington, DC, USA

A. WrightDivision of Trauma and Burns,Children’s National Medical Center,Washington, DC, USA

W. Pastor � D. C. StockwellDivision of Quality Improvement,Children’s National Medical Center,Washington, DC, USA

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