Objective: To determine whether institution of a standardized algorithm of goal-directed sedation impacted the incidence of unplanned extubations in critically ill pediatric patients.
Design: Prospective, observational study with historical controls.
Setting: Pediatric intensive care unit (PICU) in a tertiary care university-based children's hospital.
Patients: All mechanically ventilated children admitted to the PICU during a 10-yr period.
Interventions: After examining the data pertaining to unplanned extubations, the Penn State Children's Hospital Sedation Algorithm (PSCHSA) was instituted as an absolute requirement for all mechanically ventilated children. Physician orders for the goal sedation level and the appropriate medications to achieve that goal were obligatory for every ventilated patient. Data were then collected for 5 yrs after institution of the PSCHSA.
Measurements and main results: Before utilization of the PSCHSA, unplanned extubation rates ranged between 0.44 and 0.63 per 100 intubated patient days. In the 4 yrs after mandatory use of the PSCHSA for management of all ventilated patients, unplanned extubation rates were between 0 and 0.19 per 100 intubated patient days, demonstrating a significant decrease (p<.001). Throughout the entire study period, no changes were made in the model of patient care that would alter the rate of unplanned extubations. Despite a higher percentage of PICU patients that were intubated, length of stay in the PICU did not increase, suggesting that oversedation did not led to increased ventilator days.
Conclusions: Utilization of the PSCHSA resulted in a decreased number of unplanned extubations without increasing the length of PICU stay. Implementation of the PSCHSA is needed in other PICUs to validate these findings.