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Incidence of accidental extubation in patients on mechanical ventilation in the ICU of Distrito Federal


To investigate and analyze the events of accidental extubation in the ICU of Hospital Santa Luzia, Brasília.


The study was carried out from 1 July 2008 to 31 December 2008. In this period, 864 patients were admitted and 178 of them were submitted to mechanical ventilation.


In this period of 864 patients, 51.74% were male and 48.26% female. There was a predominance of patients aged over 71 years (27.66%): patients up to 20 years (18.63%), from 21 to 30 years (5.32%), from 31 to 40 years (6.6%), from 41 to 50 years (10.3%), from 51 to 60 years (14.47%), and from 61 to 70 years (17.01%). The mean APACHE II index was 10 (± 7.46) and mean SAPS II was 30.87 (± 13.31). In this period, 178 (20.60%) patients were submitted to mechanical ventilation. We observed three (1.68%) cases of accidental extubation. None of the cases required reintubation. It was necessary to use noninvasive mechanical ventilation in two patients, only in one situation was the patient in the process of weaning. In two cases there was failure to control the exchange of fixing the orotracheal tube, and the other failed in containing the patient due to psychomotor agitation during the hygiene of nursing care. Only one case occurred during the night duty, in which was found 100% occupancy of the ICU and a decrease in the number of nursing assistants by licensed health. There were no cases of death.


The monitoring conducted by the physiotherapy team and the existence of routines for exchange of a fixed endotracheal tube favor a low incidence of adverse events of accidental extubation. Although there have been no cases of death, the search for preventive mechanisms confirms the quality of care.

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Neto, J.A., Amaral, G., Bernardes, S. et al. Incidence of accidental extubation in patients on mechanical ventilation in the ICU of Distrito Federal. Crit Care 13 (Suppl 3), P61 (2009).

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