Extubation
Conditions
Brief summary
EXTUBE is an international, multicentre, prospective cohort study evaluating the incidence, risk factors, and outcomes of extubation-related complications and describing clinical practices related to extubation after general anesthesia or after critical illness in the operating room (OR), out of OR anesthesia location or intensive care unit (ICU).
Detailed description
Globally, over 200 million people each year require extubation. While routinely performed, extubation is a skilled and potentially high-risk procedure that should be performed only when physiologic, pharmacologic, and contextual conditions are optimal. Complications at this stage of patient care can result in decreased oxygen delivery to the brain and body, sometimes leading to serious adverse events such as cardiac arrest, brain damage, or death. Indeed, one quarter of airway complications that result in death or brain death occur at the time of extubation. Despite the frequency of extubation and the potential for life-threatening complications, there is a lack of systematic data on the rate and circumstances under which these severe complications occur. The limited data indicate 10-30% of extubations may lead to severe complications, depending on the population and outcome definition. However, the certainty of these estimates is severely limited because they are based on studies that are small, mostly single-center, based on clinician recall, only capture a small portion of extubation complications (e.g., malpractice claims), or do not reflect current clinical practice. In addition, most lack a denominator and exclude successful extubations, making estimates of actual complication rates and risk factors impossible. There has been no large study of extubation techniques or adherence to guidelines, so procedural factors associated with complications must be elucidated. While adherence to clinical practice guidelines has not been formally evaluated, surveys show non-adherence to some best practices and considerable variation in practice, and data from audits and medicolegal claims show that lack of adherence to best practices is frequently at the root cause of severe adverse extubation outcomes, with half of the complications deemed preventable. Therefore, data on the frequency and nature of extubation complications, patient and procedural risk factors for complications, and guideline adherence rates are needed before these preventable events can be addressed. EXTUBE (EXtubation related complications - an international observational study To Understand the impact and BEst practices in the operating room and intensive care unit) is an international, multicenter, prospective cohort study The primary objective of this study is to estimate the incidence of immediate complications related to extubation in adult patients after general anesthesia and/or after critical illness. The secondary objectives are to determine: 1) the incidence of mild extubation complications; 2) patient- and procedure-related risk factors for extubation complications; 3) the association between extubation complications and outcomes until hospital discharge; and 4) the rate of adherence to extubation clinical practice guidelines.
Interventions
None listed
Sponsors
University Health Network, Toronto
Study design
Observational model
COHORT
Time perspective
PROSPECTIVE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adult patients (≥18 years old) * Undergoing extubation of an endotracheal tube (including index extubation and re-extubations) after general anesthesia in the OR, out of OR anesthesia location or ICU * Undergoing extubation during the specified enrollment window
Exclusion criteria
* Patients will be excluded if the extubation is performed in the context of withdrawal of life support measures, * Patients will be excluded if the extubation is performed for tracheostomy decannulation For each patient who is not included, reasons for exclusion will be reported.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| At least one of the following, occurring within 60minutes after extubation (composite outcome): i) Severe hypoxemia ii) Cardiac arrest iii) Need for airway management | Within 60 minutes after the end of extubation | The primary outcome will be the occurrence of at least one of the following (composite outcome) occurring within 60 minutes after the end of extubation: i) Severe hypoxemia (oxygen saturation as measured by pulse oximetry falls below SpO2 \< 80% for \> 5 minutes) ii) Cardiac arrest iii) Need for airway management (reintubation, insertion of a supraglottic airway, bag-mask ventilation). |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Difficult airway and complications related to airway management if reintubation is required | Within 60 minutes after the end of extubation | Difficult airway (i.e., experienced difficulty by an experienced airway manager with any or all of laryngoscopy or tracheal intubation, supraglottic airway use, face-mask ventilation, or front-of-neck airway) and complications related to airway management (e.g., esophageal intubation) if reintubation is required |
| Planned and unplanned non-invasive respiratory support | Within 60 minutes after the end of extubation | Planned and unplanned non-invasive respiratory support or high flow nasal cannula |
| Emergency front of neck airway | Within 60 minutes after the end of extubation | Emergency front of neck airway should airway management be required after extubation |
| Cardiac arrhythmia requiring chemical or electrical treatment | Within 60 minutes after the end of extubation | Cardiac arrhythmia requiring chemical or electrical treatment |
| Severe Hypotension | Within 60 minutes after the end of extubation | Severe hypotension (systolic arterial pressure \< 65 mmHg recorded at any time or systolic arterial pressure \< 90 mmHg for \> 30 minutes or new need/increase of vasopressor and/or fluid load \> 15 mL/kg) |
| Severe Hypertension | Within 60 minutes after the end of extubation | Severe hypertension (systolic blood pressure ≥180 mmHg and/or diastolic blood pressure ≥120 mmHg), |
| Pulmonary aspiration | Within 60 minutes after the end of extubation | Aspiration of gastric contents (gastric contents inhaled into the larynx and the respiratory tract) |
| Barotrauma | Within 60 minutes after the end of extubation | Pneumothorax/pneumo-mediastinum |
| Dental injury | Within 60 minutes after the end of extubation | Dental injury (notable change to the patient's dentition attributable to extubation or to reintubation, should this be required) |
| Airways injury | Within 60 minutes after the end of extubation | Airways injury (e.g., vocal cord damage, arytenoid dislocation |
| Mortality | Within 7 days after extubation | In-hospital mortality |
| Re-intubation | Within 48 hours after extubation | Re-intubation within 48 hours of extubation |
Countries
Australia, Canada, Colombia, Ireland, Kuwait, New Zealand, Singapore, United Kingdom, United States
Contacts
CONTACTMatteo Parotto, MD, PhD
CONTACTShayan Wasim, MPH, BSc
PRINCIPAL_INVESTIGATORMatteo Parotto, MD, PhD
UHN
Outcome results
None listed