Division of Pediatric Critical Care Medicine, Universidade Federal de São Paulo, São Paulo.
Pediatr Crit Care Med. 2010 Mar;11(2):287-94. doi: 10.1097/PCC.0b013e3181b80951.
The aim of this study was to update the state of knowledge of unplanned extubations in the pediatric population. The main topics addressed in the current literature on unplanned extubations were: 1) incidence; 2) risk factors; 3) risk factors for reintubation after unplanned extubations; and 4) strategies to prevent unplanned extubations. Based on this review we summarize and propose best practices in preventing unplanned extubations.
MEDLINE, CINAHL, Scielo, Lilacs, and Cochrane databases were searched for bibliography for the period spanning from January 1966 to March 2009. We used the following key words: unplanned extubation, accidental extubation, self extubation, unintentional extubation, unexpected extubation, inadvertent extubation, spontaneous extubation, and treatment interference.
Eleven pediatric articles were eligible for data abstraction. Study quality was assessed using four levels of aggregate evidence adapted from the American Academy of Pediatrics.
Unplanned extubations occurs at a rate of 0.11 to 2.27 events per 100 intubation days. Risk factors associated with unplanned extubations were age (younger patients), inadequate tube fixation, agitation, copious secretions, performance of patient procedures, and nursing workload. Reintubation rates ranged from 14% to 65% of unplanned extubations. Three cohort studies evaluated the effectiveness of strategies in reducing unplanned extubations. One study reported the institution of a standardized algorithm of goal-directed sedation, whereas two studies evaluated the implementation of a continuous quality-improvement program. These studies reported significant reductions in unplanned extubations rate after program implementation. Methods of securing the endotracheal tube varied across studies and the use of physical restraints yielded conflicting findings.
There are few studies assessing unplanned extubations in pediatric intensive care units. The available quality studies have shown that improvement of quality components is effective in reducing unplanned extubations. Although further rigorous studies are needed to establish strong recommendations on unplanned extubations prevention, we present a summary of recommendations based on review of the current literature.
本研究旨在更新小儿人群中意外拔管的知识状况。当前关于意外拔管的文献主要涉及以下几个方面：1）发生率；2）危险因素；3）意外拔管后再插管的危险因素；4）预防意外拔管的策略。基于这一综述，我们总结并提出了预防意外拔管的最佳实践。
1966 年 1 月至 2009 年 3 月期间，检索了 MEDLINE、CINAHL、Scielo、Lilacs 和 Cochrane 数据库以获取文献目录。我们使用了以下关键词：意外拔管、意外拔管、自行拔管、非计划性拔管、意外拔管、意外拔管、自发性拔管和治疗干扰。
有 11 篇儿科文章符合数据提取标准。使用美国儿科学会改编的四个综合证据水平评估研究质量。
意外拔管的发生率为每 100 个插管日 0.11 至 2.27 例。与意外拔管相关的危险因素包括年龄（较小的患者）、管固定不当、躁动、大量分泌物、患者操作、护理工作量。再插管率为意外拔管的 14%至 65%。三项队列研究评估了减少意外拔管策略的有效性。一项研究报告了采用目标导向镇静标准化算法，而两项研究评估了实施持续质量改进计划。这些研究报告说，在实施该方案后，意外拔管的发生率显著降低。在不同的研究中，固定气管导管的方法不同，使用身体约束也有相互矛盾的发现。
评估小儿重症监护病房意外拔管的研究很少。现有的高质量研究表明，改善质量成分可有效减少意外拔管。尽管需要进一步进行严格的研究来建立关于预防意外拔管的强有力建议，但我们根据对当前文献的回顾提出了一份建议摘要。
