Since the 1990’s one of the key components of “clinical pathways” for cardiac surgery has been early extubation of patients, often protocol-based. That was a key to reducing ICU lengths of stay for such patients.
Indeed, one study heavily weighted toward cardiothoracic surgery patients (Tischenkel 2016) found that intensive care unit extubations at night did not have higher likelihood of reintubation, LOS, or mortality compared to those during the day. In fact, trends in that study favored nighttime extubation for both reintubation rates and mortality and those extubated at night had significantly lower lengths of stay.
Given the complications associated with mechanical ventilation and extended intubation, it might seem wise that patients should be extubated as soon as possible. Those complications include ventilator-associated pneumonias, delirium, neuromuscular syndromes, etc. Hence, there might be theoretical reasons to favor early extubation. But what are the empirical data favoring overnight extubation? A new study looks at patient outcomes in patients who were extubated overnight and has some surprising results (Gershengorn 2016). In a retrospective analysis of a cohort of almost 100,000 mechanically ventilated patients they found 20.1% were extubated overnight and that rate has decreased over time. For those patients who had been mechanically ventilated for less than 12 hours reintubation rates were similar between those extubated overnight vs. during the daytime but mortality was increased for those extubated overnight (5.6% vs. 4.6%). For those mechanically ventilated more than 12 hours, those extubated overnight had higher reintubation rates and higher ICU and hospital mortality with no difference in length of stay.
One intriguing finding was that the odds ratios for increased mortality in those extubated overnight were higher than the odds ratios for reintubations. While several possible reasons were discussed by the authors, they favored a hypothesis that “palliative” extubations may have accounted for this (with the theory that palliative extubations are more likely to take place when family is present at night).
They also attributed the disparity between their study and that by Tischenkel and colleagues (Tischenkel 2016) to a significant difference in the number of patients undergoing cardiothoracic surgery.
Keep in mind that the Gershengorn study was a retrospective cohort study. As pointed out in the accompanying editorial (Moore 2016), though the study had excellent data collection as part of a large collaborative study there was lack of information on the circumstances and reasons for extubation (and reasons why some were not reintubated).
In our September 20, 2016 Patient Safety Tip of the Week “” we discussed a study (Balas 2013a , Balas 2014) that was a prospective, cohort, before-after study of the ABCDE bundle at a large, tertiary medical center, involving patients from multiple ICU’s. They found patients treated with the ABCDE bundle, which leads to earlier extubation, experience more days breathing without assistance and a shorter duration of ICU delirium. The odds of delirium were cut almost in half. Patients on the bundle were also more likely to be mobilized out of bed during their ICU stay. No significant differences were noted in self-extubation or reintubation rates. But it should be noted that one of the barriers encountered in implementation was that nurses and respiratory therapists were often concerned about spontaneous breathing trials being done at night (Balas 2013b).
Though the findings of the Gershengorn study are associations and do not prove causality, they certainly put to question the practice of overnight extubations. We suspect that there may well be differences in outcomes both by type of ICU and nature of the underlying problem. But it is certainly worth all hospitals taking a look at their current practices and outcomes.
Tischenkel BR, Gong MN, Shiloh AL, et al. Daytime vs nighttime extubations: a comparison of reintubation, length of stay, and mortality. J Intensive Care Med 2016; 31(2): 118-126
Gershengorn HB, Scales DC, Kramer A, Wunsch H. Association between Overnight Extubations and Outcomes in the Intensive Care Unit. JAMA Intern Med 2016; Published Online First September 06, 2016
Moore PK, Matthay MA. Overnight Extubation in Patients with Mechanical Ventilation. Is It Harmful? JAMA Intern Med 2016; Published online September 06, 2016
Balas M, Olsen K, Gannon D, et al. Safety And Efficacy Of The ABCDE Bundle In Critically-Ill Patients Receiving Mechanical Ventilation. Abstract at Society of Critical Care Medicine 42nd Critical Care Congress. Presented January 20, 2013. Crit Care Med 2012; 40(12) (Suppl.): 1
Balas MC, Vasilevskis EE, Olsen KM, et al: Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014; 42: 1024-1036
Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med 2013; 41(9 Suppl 1): S116-127