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1002 Monitoring and Prevention of Unplanned Extubations
  1. DK White,
  2. ME Harvey
  1. Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK


Background and Aims Unplanned Extubations (UE’s) are potentially life threatening events1. They can result in traumatic reintubations which in turn can lead to tracheal damage. The monitoring and prevention of these incidents is of paramount importance to the safety of children in the paediatric intensive care unit (PICU).

Methods A previous audit of UE’s had been conducted between August 2010 and April 2011 as we had noticed a sharp increase in incidence. Although the rate of 0.56/100 ventilator days was within the expected range of 0.11–2.27/100 ventilator days1, we identified staffing levels and sedation as key areas which appeared to have some causal effect on these numbers. Following the audit, staff were made aware of the increase in UE’s and the importance of prevention was highlighted.

Results Between May 2011 and March 2012. all incident forms were examined and those relating to ‘accidental extubations’ or ‘tube displacement’ were examined in more detail. During this time period it was noted that the UE rate was 0.65/100 ventilator days.

Conclusion Despite reviewing the sedation policy and staffing levels, the UE rate remains unchanged. It is possible that the heightened awareness of staff has increased the reporting rate but there is no evidence of this. Although our UE rate remains low we will continue to examine each case individually and review practice as necessary.

1. da Silva et al 2010. Pediatr Crit Care Med. Unplanned extubation in pediatric critically ill patients.

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