Self-extubation in critically ill patients: new predictors identified in a multicenter retrospective study
Abstract
Introduction: Although COVID-19 is now considered an endemic disease, understanding the factors associated with planned extubation and self-extubation in this population remains essential.
Objective: To identify factors associated with self-extubation, planned extubation and mortality in patients with severe SARS-CoV-2 pneumonia.
Methods: Retrospective, multicenter, analytical cohort study conducted between July 2020 and August 2021 in the ICUs of two quaternary hospitals in Bogotá, Colombia. Patients older than 16 years requiring invasive mechanical ventilation for severe SARS-CoV-2 pneumonia (confirmed by RT-PCR or serology) were included. Severe cases were defined according to established clinical and radiological criteria. Data were collected retrospectively from electronic medical records by independent investigators using standardized tools to assess pain (VAS, BPS), delirium (CAM-ICU), and illness severity (APACHE IV). Patients with incomplete follow-up, early death (<24h), referral to another institution, or therapeutic limitation were excluded. Descriptive statistics summarized demographic and clinical variables. Associations with self-extubation, planned extubation, and mortality were first explored by bivariate tests, and then multivariate analyses were performed using generalized estimating equations to adjust for potential confounders. A p-value <0.05 was considered statistically significant.
Results: A total of 1109 patients were included. Mean age was 58.5 years (SD ± 12.8), 68.9% were men, and the mean APACHE IV score was 40.5 (SD ± 16.5). High blood pressure (36.22%) and type 2 diabetes mellitus (21.7%) were the most common comorbidities. Self-extubation and planned extubation were reported in 81 (7.1%) and 595 (77.18%) patients respectively; 338 (30.48%) died. The physical restraint was found to be a predictor of self-extubation (OR: 5.18; 95% CI: 2.43-12.10). Planned extubation was favored by family companionship (OR: 3.45; 95% CI: 1.19 to 9.93) and dexmedetomidine use (OR: 15.36; 95% CI: 9.06 to 26.02). Pain and delirium were not associated with self-extubation. Finally, disease severity (OR:1. 03; 95% CI: 1.00 to 1.02) and older age (OR: 1.05; 95% CI: 1.03 to 1.07) were associated with mortality, while dexmedetomidine behaved as a protective factor (OR: 0.04; 95% CI: 0.02 to 0.08).
Conclusions: Clinical and contextual factors were associated with both extubation outcomes and mortality. The use of physical restraints in mechanically ventilated patients was linked to a higher risk of self-extubation, while family presence and dexmedetomidine use were associated with an increased likelihood of planned extubation.
References
1. (JHU) JHU. COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) [Internet]. Global Map. [cited 4 Oct 2024]. Available at: https://coronavirus.jhu.edu/map.html
2. Townsend JP, Hassler HB, Lamb AD, Sah P, Nishio AA, Nguyen C, et al. Seasonality of endemic COVID-19. mBio. 2023;14(6):e0142623. https://doi.org/10.1128/mbio.01426-23
3. Estrada-Chiroque LM, Orostegui-Arenas M, Burgos-Guanilo MDP, Amau-Chiroque JM. Clinical characteristics and maternal perinatal outcome in women with a confirmed diagnosis of COVID-19 in a hospital in Peru. Retrospective cohort study. Rev Colomb Obstet Ginecol. 2022;73(1):28-38. https://doi.org/10.18597/rcog.3776
4. Uy ABC, Ramos EFP, Rivera AS, Maghuyop NL, Suratos CTR, Miguel RTD, et al. Incidence, risk factors, and outcomes of unplanned extubation in adult patients in a resource-limited teaching hospital in the Philippines: a cohort study. Rev Bras Ter Intensiva. 2019;31(1):79-85. https://doi.org/10.5935/0103-507X.20190012
5. Chao CM, Lai CC, Chan KS, Cheng KC, Ho CH, Chen CM, et al. Multidisciplinary interventions and continuous quality improvement to reduce unplanned extubation in adult intensive care units: A 15-year experience. Medicine (Baltimore). 2017;96(27):e6877. https://doi.org/10.1097/MD.0000000000006877
6. Ai ZP, Gao XL, Zhao XL. Factors associated with unplanned extubation in the Intensive Care Unit for adult patients: A systematic review and meta-analysis. Intensive and Critical Care Nursing. Churchill Livingstone; 2018;47:62-8. https://doi.org/10.1016/j.iccn.2018.03.008
7. Higgs A, Cook TM, McGrath BA. Airway management in the critically ill: The same, but different. British Journal of Anaesthesia. 2016;117(Supl.1):I5-9. https://doi.org/10.1093/bja/aew055
8. Laverde-Sabogal CE, Espinosa-Almanza CJ, Patiño-Hernández D, Rodríguez-Escallón H, Aguado-Valderrama JC, Lara-Monsalve P. Risk factors of self-extubation in intensive care. Retrospective cohort study. Colombian Journal of Anesthesiology. 2023;51(2):e1050. https://doi.org/10.5554/22562087.e1050
9. Chhina AK, Loyd GE, Szymanski TJ, Nowak KA, Peruzzi WT, Yeldo NS, et al. Frequency and Analysis of Unplanned Extubation in Coronavirus Disease 2019 Patients. Crit Care Explor. 2020;2(12):e0291. https://doi.org/10.1097/CCE.0000000000000291
10. Ministerio de Salud y Protección Social. Lineamientos para el manejo clínico de pacientes con infección por nuevo coronavirus COVID-19 [Internet]. 2020. [cited 4 Oct 2024]. Available at: https://www.minsalud.gov.co/Ministerio/Institucional/Procesos%20y%20procedimientos/PSSS03.pdf
11. Trujillo CHS. Consenso colombiano de atención, diagnóstico y manejo de la infección por SARS-COV-2/COVID 19 en establecimientos de atención de la salud. Recomendaciones basadas en consenso de expertos e informadas en la evidencia. Infectio. 2020;24(3):1. https://doi.org/10.22354/in.v24i3.851
12. Ministerio de Salud y Protección Social. Instrucciones para el registro, codificación y reporte de enfermedad respiratoria aguda causada por el nuevo coronavirus COVID-19, en los registros médicos de morbimortalidad del sistema de salud [Internet]. [cited 4 Oct 2024]. Available at: https://www.minsalud.gov.co/Ministerio/Institucional/Procesos%20y%20procedimientos/PSPS01.pdf
13. Ko M, Shim M, Lee SM, Kim Y, Yoon S. Performance of APACHE IV in Medical Intensive Care Unit Patients: Comparisons with APACHE II, SAPS 3, and MPM0 III. Acute and Critical Care. 2018;33(4):216-21. https://doi.org/10.4266/acc.2018.00178
14. Kotfis K, Zegan-barańska M, Szydłowski Ł, Żukowski M, Ely EW. Methods of pain assessment in adult intensive care unit patients - Polish version of the CPOT (Critical Care Pain Observation Tool) and BPS (Behavioral Pain Scale). Anaesthesiology Intensive Therapy. 2017;49(1):66-72. https://doi.org/10.5603/AIT.2017.0010
15. Tobar E, Romero C, Galleguillos T, Fuentes P, Cornejo R, Lira MT, et al. Método para la evaluación de la confusión en la unidad de cuidados intensivos para el diagnóstico de delírium: adaptación cultural y validación de la versión en idioma español. Med Intensiva. 2010;34(1):4-13. https://doi.org/10.1016/j.medin.2009.04.003
16. Trujillo CHS. Consenso colombiano de atención, diagnóstico y manejo de la infección por SARS-COV-2/COVID 19 en establecimientos de atención de la salud. Recomendaciones basadas en consenso de expertos e informadas en la evidencia. Infectio. 2020;24(3):1. https://doi.org/10.22354/in.v24i3.851
17. The RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. New England Journal of Medicine. 2021;384(8):693-704. https://doi.org/10.1056/NEJMoa2021436
18. Nores M, Díaz M. Construcción de modelos GEE para variables con distribución simétrica. Rev SAE. 2005;9:43-63.
19. Ai Z ping, Gao X lan, Zhao X lei. Intensive & Critical Care Nursing Factors associated with unplanned extubation in the Intensive Care Unit for adult patients : A systematic review and meta-analysis. Intensive Crit Care Nurs. 2018;47:62-8. https://doi.org/10.1016/j.iccn.2018.03.008
20. Chima A, Mahmoud M, Narayanasamy S. What Is the Role of Dexmedetomidine in Modern Anesthesia and Critical Care? Adv Anesth. 2022;40(1):111-30. https://doi.org/10.1016/j.aan.2022.06.003
21. Gouel-Cheron A, Neukirch C, Aubier B, Montravers P, Nicaise P, Chollet-Martin S, et al. Anaphylactic bronchospasm during general anesthesia is not related to asthma. Allergy. 2015;70(4):453-6. https://doi.org/10.1111/all.12565
22. Bar-Tur L, Inbal-Jacobson M, Brik-Deshen S, Zilbershlag Y, Pearl Naim S, Brick Y. Telephone-Based Emotional Support for Older Adults during the COVID-19 Pandemic. J Aging Soc Policy. 2021;33(4-5):522-38. https://doi.org/10.1080/08959420.2021.1924414
23. Guzatti NG, Klein F, Oliveira JA, Rático GB, Cordeiro MF, Marmitt LP, et al. Predictive Factors of Extubation Failure in COVID-19 Mechanically Ventilated Patients. J Intensive Care Med. 2022;37(9):1250-5. https://doi.org/10.1177/08850666221093946
24. Li P, Sun Z, Xu J. Unplanned extubation among critically ill adults: A systematic review and meta-analysis. Intensive Crit Care Nurs. 2022;70:103219. https://doi.org/10.1016/j.iccn.2022.103219
25. Guillemin J, Rieu B, Huet O, Villeret L, Pons S, Bignon A, et al. Prospective multi-center evaluation of the incidence of unplanned extubation and its outcomes in French intensive care units. The Safe-ICU study. Anaesth Crit Care Pain Med. 2024;43:101411. https://doi.org/10.1016/j.accpm.2024.101411
26. Guan W jie, Ni Z yi, Hu Y, Liang W hua, Ou C quan, He J xing, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020;382(18):1708-20. https://doi.org/10.1056/NEJMoa2002032
27. Lim ZJ, Subramaniam A, Reddy MP, Blecher G, Kadam U, Afroz A, et al. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. Am J Respir Crit Care Med. 2021;203(1):54-66. https://doi.org/10.1164/rccm.202006-2405OC
28. Pandharipande PP, Pun BT, Herr DL, Maze M, Girard TD, Miller RR, et al. Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated PatientsThe MENDS Randomized Controlled Trial. JAMA. 2007;298(22):2644-53. https://doi.org/10.1001/jama.298.22.2644
29. Kawazoe Y, Miyamoto K, Morimoto T, Yamamoto T, Fuke A, Hashimoto A, et al. Effect of Dexmedetomidine on Mortality and Ventilator-Free Days in Patients Requiring Mechanical Ventilation With Sepsis: A Randomized Clinical Trial. JAMA. 2017;317(13):1321-8. https://doi.org/10.1001/jama.2017.2088
30. Ding HZ, Dong YL, Zhang KY, Bai JY. Comparison of Dexmedetomidine Versus Propofol in Mechanically Ventilated Patients With Sepsis: A Meta-Analysis of Randomized Controlled Trials. Front Pharmacol. 2022;13:901898. https://doi.org/10.3389/fphar.2022.901898
31. Hu Y, Sun J, Dai Z, Deng H, Li X, Huang Q, et al. Prevalence and severity of corona virus disease 2019 (COVID-19): A systematic review and meta-analysis. J Clin Virol. 2020;127:104371. https://doi.org/10.1016/j.jcv.2020.104371
32. Barja-Martínez E, García-González S, Jiménez-García E, Thuissard-Vasallo IJ, Arias-Rivera S, Blanco-Abril S. Prone positioning in COVID-19 patients with acute respiratory distress syndrome and invasive mechanical ventilation. Enferm Intensiva. 2023;34(2):70-9. https://doi.org/10.1016/j.enfie.2022.09.002
33. Choi WY. Mortality Rate of Patients With COVID-19 Based on Underlying Health Conditions. Disaster Med Public Health Prep. 2021;1-6. https://doi.org/10.1017/dmp.2021.139
34. Vandenbrande J, Verbrugge L, Bruckers L, Geebelen L, Geerts E, Callebaut I, et al. Validation of the Acute Physiology and Chronic Health Evaluation (APACHE) II and IV Score in COVID-19 Patients. Crit Care Res Pract . 2021;2021:5443083. https://doi.org/10.1155/2021/5443083
Downloads
Copyright (c) 2025 Sociedad Colombiana de Anestesiología y Reanimación (S.C.A.R.E.)
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
| Article metrics | |
|---|---|
| Abstract views | |
| Galley vies | |
| PDF Views | |
| HTML views | |
| Other views | |
