Effects of Extubation Guideline Adherence on Extubation Failure Rate Among Mechanically Ventilated Paediatric Patients at the Kenyatta National Hospital.

Abstract

BACKGROUND Children, especially those under 5 years of age, are especially at risk of death from preventable and/or reversible causes particularly in resource-limited settings, which generally have sparse critical care resources. There is no accepted gold standard on extubation practice, and only minimal literature from Africa. At the Kenyatta National Hospital, guidelines based on international literature are utilised, but timing of extubation continues to rely heavily on clinical judgement. Little is known regarding the prevalence of extubation failure (EF) in our setting, or the effect of following our current guidelines on the extubation failure rate. STUDY OBJECTIVE This study sought to determine the rate of adherence to extubation guidelines and the prevalence of extubation failure among paediatric patients extubated at the Kenyatta National Hospital main and paediatric ICUs. The third objective was to describe the effect of extubation guideline adherence on extubation failure rate among these mechanically ventilated paediatric patients at the Kenyatta National Hospital. METHODS The study was a hospital based, retrospective, observational cohort study set in the main ICU and paediatric ICU at Kenyatta National Hospital. The participants were children aged 1 month to 12 years admitted to the ICU/PICU from November 1, 2017 to February 28, 2018 who received mechanical ventilation via endotracheal tube and have an attempted extubated during their stay in the ICU. An informed consent was obtained for all participants enrolled in the study. A standard data collection tool was used for data collection. Data was stored in MS-EXCEL and analysed using STATA 12® software. RESULTS The study enrolled 56 out of 84 possible eligible participants aged between 1 month to 12 years, with a total of 62 extubation attempts recorded. Of the participants, 57.2% were male, and majority of them (89.3%) were below the age of 5 years, with median age of 13.5 months (IQR 2 months – 82 months). Respiratory and neurological diagnoses were a common reason for intubation in these patients. More than half of the extubations (59.7%) were carried out in PICU with the rest being in the main ICU. A high incidence of xiii unplanned extubations (22.6%) was noted. Only 3 to 8 of the 9 criteria were followed for each extubation. None of the extubations were carried out in adherence to all 9 criteria of the guidelines, and most of the extubations (74%) met between 5 to 7 of the guidelines. The overall extubation failure (EF) rate was 11.3%. EF rate was not significantly different when comparing planned and unplanned extubations. Use of adrenaline nebulisation, control of underlying disease and hemodynamic stability evidenced by no inotropic support in the 24 hours pre-extubation were the 3 parameters shown to be associated with reduced risk of EF after bivariate analysis. Multivariate analysis however did not show a significant association. CONCLUSION The KNH paediatric extubation guidelines are only partly adhered to in planning for extubation in the ICUs. Despite this however, our EF rate of 11.3% is comparable to documented rates worldwide. Of the 9 criteria, 2 (control of underlying disease and hemodynamic stability) were shown to be protective against EF even in a small population. The high rate of unplanned extubations and low EF rate in unplanned extubations suggests that our approach to assessing extubation readiness may be too conservative. RECOMMENDATIONS There is need to improve awareness of the healthcare workers in these ICUs on the extubation guidelines, particularly those that have been shown to have significant effect on EF. Early weaning and extubation of our paediatric patients may have benefit. Clinical judgement of a trained and experienced ICU specialist remains vital in determining the best time to extubate patients, but the guidelines remain useful for less experience healthcare workers in an ICU setting. Further studies assessing post extubation use of adrenaline nebulization as an independent variable are indicated in our setting.