Prospective multi-centre evaluation of the incidence of unplanned extubation and its outcomes in intensive care units. The Safe-ICU study

Background: The lack of a clear definition and strong methodology has led to differing results in terms of unplanned extubation (UE) epidemiology and outcomes. We aimed to determine the UE incidence and clinical significance of both accidental extubation and self-extubation. Methods: : A multicentric prospective cohort study was conducted in 47 French ICUs. The number of mechanical ventilation (MV) days, planned and unplanned extubation were recorded in each centre over a minimum period of three consecutive months to evaluate UE incidence. Patient characteristics, UE environmental factors, and outcomes (follow-up until ICU discharge or day 28) were compared based on the UE mechanism (accidental or self-extubation). Finally, we determined ‘failed’ self-extubation (re-intubation at day 7) prognosis and risk factors. Results: : During the 12-month inclusion period, we found a pooled UE incidence of 1.0 per 100 MV days. UE accounted for 9% of all endotracheal removals. Of the 635 UE, 88% were self-extubations and 12% were accidental extubations. The latter had a worse prognosis than self-extubations (34% vs 14% mortality, p <0.001). Self-extubation failure, which occurred in 35% of self-extubation patients, was associated with excess mortality (15% vs 4%, p <0.001). Cancer, higher respiratory rate, lower PaO 2 /FiO 2 , weaning process not ongoing, and immediate post-extubation respiratory failure were independent predictors of failed self-extubation. Discomfort was the leading cause of self-extubation reported by both patients and physicians, ahead of agitation. Conclusion: Unplanned extubation is common in ICU and accounts for 9% of all endotracheal removals. Accidental extubation has a poorer prognosis than self-extubation.