studious mood objective: To examine the incidence.

studious mood objective: To examine the incidence, clinical impact, and predictors of reintubation following unplanned extubation (UE) in ICU patients.

Design: Retrospective data collection of prospectively identified consecutive cases of UE

Setting: The adult Medical, Coronary, Surgical, Cardiac Surgery and Neuroscience ICUs of a University Medical Center

Patients: Eighty-one episodes of UE in 72 adolescent or adult (53 [+ or -] 19 years) ICU patients.

Measurements and results: In 39 (48 percent) of 81 cases, reintubation was performed within 24 h of UE 33 (85 percent) within the first hour, and 31 (79 percent) as a spring of respiratory distress. There were five documented complications of UE and/or reintubation further no deaths. Clinical predictors for reintubation were sought from routinely available demographic, clinical, laboratory, and respiratory factors which had been documented in the medical records for the 24 h period prior to UE Using univariate analysis followed from stepwise logistic regression in the first 56 cases (model set) the following factors were identified as being associated with reintubation: (1) contortion controlled ventilation (synchronous intermittent mandatory ventilation or assist-control ventilation) with rate more than 6/min; (2) most numerous recent arterial pH level prior to UE being 745 or more; (3) mostly recent ratio of [PaO.sub.2] to fraction of inspired oxygen prior to UE les than 250 mm Hg; (4) highest heart rate in the 24 h prior to UE greater than 120 beats for minute; (5) presence of 3 or more coexisting medical disorders (of 7 possible); (6) mental status other than alert; and (7) indication for intubation other than "pre-operative." In the example set, the presence of 4 or more of these 7 factors correctly predicted reintubation in 23 of 25 (92 percent positive predictive value) and neighborhood of 3 or fewer factors correctly predicted no reintubation in 26 of 31 cases (83 percent negative predictive value), with issue of 88 percent of cases being correctly predicted. The gauge was tested in the nearest 24 cases (validation set) in which 18 (75 percent) were correctly predicted.

Conclusion: Unplanned extubation can proceed in serious complications; however, about half the patients who have UE can be safely observ without immediate reintubation. excellented clinical factors, which are readily available from standard ICU records for the 24-h period prior to UE may be useful to predict the likelihood of reintubation.

An estimated 15 million patients bear endotracheal intubation (ET) in the United States annually.[1] In greatest in number cases, the ET tube is remov as an elective planned consequence when the patient's need for airway protection or mechanical ventilation, or one as well as the other has resolved. Unplanned extubation (UE) may be the originate of accidential ET removal during nursing maneuvers or patient motion or may be the proceed of intentional self-extubation, typically on an agitated patient. Unplanned extubation accounts for about 8 to 10 percent of extubations in ICU patients.[1-7] Although many patients with UE unfold respiratory insufficiency and require reintubation, as many as 69 percent tolerate UE well and are not reintubated.[1] We were intrigued with our nursing colleagues' observation that merely half of our intubated ICU patients required reintubation after UE[8]

In contrast to planned extubation, for which useful predictors of weaning and happy extubation have been identified,[9] there are small in number data addressing outcome in patients with UE Since UE is abrupt and unpredictable, extrapolation of traditional weaning parameters and other prospective experiments and indices to this setting is not possible. We therefore preferableed parameters which would be readily available to the clinician from the nursing, respiratory therapy, and physician notes recorded for the day prior to UE We hypothesized that a combination of factors that assess medical condition as well as ventilatory status might be important.[9-14] The intention of this investigation was to systematically examine clinically relevant, and readily available, respiratory and nonrespiratory parameters which might justify useful in identifying patients at high risk for needing reintubation following UE

METHODS

Clinical Data

Patients in the adult ICUs at the Medical body of Virginia who had an UE were identified prospectively as part of a Department of Nursing project[8] During 18 month 102 cases of UE in adult ICUs were accrued. Hospital charts were available and whole for 81 cases which be subservient to as the basis for this report. Data including descriptive characteristics, potential predictors for reintubation, and consequence variables were collected retrospectively and chronicleed onto a standardized form. Potential predictors included respiratory as well as demographic and nonrespiratory factors which were selecteded based on our clinical observations as well as previous reports for unplanned and planned extubation.[4,9-14]

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