Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit.

OBJECTIVE: Unplanned extubation (UEX) is a potentially serious complication of mechanical ventilation. Limited information is available regarding factors that contribute to UEXs and subsequent reintubation of children. We monitored UEXs in our pediatric intensive care unit (PICU) for a 5-year period to assess the incidence and patient conditions associated with UEX and to evaluate whether targeted interventions were associated with a reduced rate of UEXs. METHODS: Over a 5-year period, demographic and clinical information was collected prospectively on all patients who required an artificial airway while admitted to the PICU. Additional information was collected for patients who experienced an UEX. Educational sessions and care management protocols were developed, implemented, and modified according to issues identified via the monitoring program. RESULTS: From a total of 2192 patients who required 13 630 airway days (AWD), 141 (6%) patients experienced 164 UEXs. The overall rate of UEX for the study period was 1.2 UEXs per 100 AWD, and this rate decreased from 1.5 in the first year to 0.8 in the last year. UEXs were more common in children who were younger than 5 years (1.6 vs 0.6 UEX per 100 AWD) compared with older children. The UEX children experienced significantly longer length of mechanical ventilation (6 vs 3 days) and longer length of PICU stay (8 vs 4 days) compared with non-UEX children. Forty-six percent of the UEXs occurred in patients who were weaning from mechanical ventilation, and 22% of those patients required reintubation. CONCLUSIONS: We conclude that UEX in pediatric patients is associated with longer length of mechanical ventilation and length of stay in the PICU. A continuous quality improvement monitoring and educational program that identified high-risk patients for UEX (younger patients) and patients who were at low risk for subsequent reintubation (weaning patients) contributed to a reduction of these potentially adverse events.

Pediatric extracorporeal life support after high frequency ventilation: predictors of survival.

Previous studies of extracorporeal life support in pediatric patients have identified variables associated with survival. However, none of these studies focused on extracorporeal life support after failure of high frequency ventilation (HFV). In the present study, we determined variables associated with survival for pediatric respiratory failure patients who received HFV prior to extracorporeal life support, using data reported to the Extracorporeal Life Support Organization Registry from 1992 to 1998. Patients with neonatal diagnoses, immune compromising conditions, or congenital cardiac defects were excluded. The 243 patients who met inclusion criteria had a 58% survival rate (95% CI 48-66%). The mean age was 22 +/- 39 months. Mean duration of mechanical ventilation prior to extracorporeal life support was 6.6 +/- 5.8 days. Venoarterial extracorporeal life support was used in 72% of the patients; venovenous in 28%. The survival rate for the subset of patients with an oxygenation index greater than 42 cm H2O/torr on HFV (n = 122) was not significantly different from the overall sample. We determined that lower mean airway pressure, lower pressure amplitude, decreased oxygenation index, increased PaO2, and increased oxygen saturation on HFV were associated with increased survival in patients who were subsequently treated with extracorporeal life support.