Overnight extubations linked to increased in-hospital and ICU mortality

1. In a retrospective cohort study of patients receiving mechanical ventilation in an ICU who underwent overnight extubations, there was an increase in ICU and hospital mortality compared with patient extubated during the daytime.

2. Patients undergoing overnight extubations were more likely to have mechanical ventilation (MV) duration of less than 12 hours and require re-intubation, but had shorter ICU length of stay.

Evidence Rating Level: 2 (Good)       

Study Rundown: Mechanical ventilation is a common intensive care unit (ICU) intervention that can be associated with many complications such as deconditioning, delirium, and ventilator-associated pneumonia. Reduction in the total length of time under MV can minimize these complications. Elective extubations, however, are commonly deferred to daytime when ICU staffing may be optimal. The described study sought to evaluate any difference in outcomes between patients who were extubated overnight compared to those extubated during the day.

Data from a large, multi-center database (Project IMPACT) of ICUs in the United States was used to create a cohort of patients who underwent overnight extubations. Factors associated with overnight extubations included MV less than 12 hours, and admission from an operating room setting, or for non-respiratory primary diagnoses. For patients ventilated for less than 12 hours, there were no differences in rate of reintubation and ICU length of stay (LOS) was shorter in the overnight extubations cohort. For patients with greater than 12 hours of MV, overnight extubation was linked to increased rate of reintubation. In all patients, there was increased rate of ICU and in-hospital mortality associated with overnight extubations. While the cohort was large and represented wide-ranging ICU population, reasoning for extubation was not captured in the study, which may be used to explain some of differences seen in the study.

Click to read the study, published today in JAMA Internal Medicine

Relevant Reading: Daytime Versus Nighttime Extubations: A Comparison of Reintubation, Length of Stay, and Mortality

In-Depth [retrospective cohort]: This study used data from the Project IMPACT database, which encompassed patients in the US admitted to ICUs from October 1, 2000 to March 29, 2009. The study population was 97 844 adults over the age of 18, who underwent a first episode of MV. Patients were excluded if they died, received tracheostomy, or had a change in goals of care before the first attempt at extubation. Overnight extubation was defined as taking place between 1900H and 0659H. For comparisons between overnight and daytime extubation outcomes, propensity-matched pairs were made to account for known covariates.

Overnight extubation occurred in 20.1% of patients, and was associated with admissions from post-surgical settings (63.5% vs. 40.2%, p < 0.001), MV less than 12 hours (57.1% vs. 19.8%, p < 0.001), and were less likely to have a primary respiratory diagnosis (16.2% vs. 30.1%, p < 0.001). In propensity matched analysis, in patients with <12 hours MV there was increased ICU mortality (5.6% vs. 4.6%, p = 0.03), hospital mortality (8.3% vs. 7.0%, p = 0.01), and shorter ICU LOS (p < 0.001). Rate of reintubation was not significantly different. In patients who underwent greater than 12 hours of MV rates of reintubation (14.6% vs. 12.4%, p < 0.001), ICU mortality (11.2% vs. 6.1%, p < 0.001), and hospital mortality (16.0% vs. 11.1%, p < 0.001) were all greater in patients who underwent overnight extubation.

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