By Kathryn Radigan, MD, MSc
Attending Physician, Division of Pulmonary and Critical Care, Stroger Hospital of Cook County, Chicago
Dr. Radigan reports no financial relationships relevant to this field of study.
SYNOPSIS: Compared to daytime extubations, ICU patients who undergo planned extubation at night do not experience higher likelihood of reintubation, increased length of stay, or increased mortality.
SOURCE: Tischenkel BR, Gong MN, Shiloh AL, et al. Daytime versus nighttime extubations: A comparison of reintubation, length of stay, and mortality. J Intensive Care Med 2016;31:118-126.
Although studies have shown that aggressive extubation protocols lead to decreased length of stay (LOS) and improved outcomes, the safety of planned nighttime extubations is unknown. Tischenkel et al conducted a retrospective cohort study of mechanically ventilated patients from July 2009-May 2011 to determine whether nighttime extubations were associated with higher reintubation rates, mortality, or LOS. The trial was conducted in two hospitals within a tertiary academic medical center that included all adult ICU patients except for those extubated due to withdrawal of life support. Patients who were extubated between 7:00 a.m. and 6:59 p.m. were considered the daytime group, and those extubated between 7:00 p.m. and 6:59 a.m. were considered the nighttime group. Nighttime staffing included attending physicians, respiratory therapists, and fellows who were in-house at all times but took care of twice the number of ICU patients when compared to daytime hours. The nursing ratio in all ICUs was 1:2 at all times. Of the 2,240 extubated patients analyzed, 1,555 were daytime extubations and 685 were nighttime extubations. For the patients who were extubated during the day, 119 were reintubated within 24 hours, compared with 26 in the nighttime group after multivariable adjustment (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3-0.9; P = 0.01). At 72 hours, there was a similar trend that was not statistically significant (OR, 0.7; 95% CI, 0.5-1.0; P = 0.07). Additionally, there was a trend toward decreased mortality for patients who were extubated at night (OR, 0.6; 95% CI, 0.3-1.0; P = 0.06) along with a lower LOS (P = 0.002). Patients who were extubated at night did not have higher likelihood of reintubation, LOS, or mortality when compared to patients who underwent daytime extubation.
COMMENTARY
Although this trial appeared to be conclusive, clinicians should discern whether this trial may be safely applied in their specific patient population. First, 82% of patients who were extubated overnight were from the cardiac surgery intensive care unit (CSICU). Since studies have shown that early extubation in cardiac surgery patients is associated with decreased LOS, morbidity, and mortality, patients from the CSICU were under protocols with the goal to extubate within 6 hours of the end of surgery. With this protocol in mind, it is more than likely the majority of the nighttime extubations were less critical in post-surgical patients who strictly met extubation criteria. Although the authors attempted to adjust for severity of illness with the Elixhauser score, this is a less commonly used severity of illness score, and the authors agreed that the statistical adjustment may be incomplete.
Furthermore, ICUs involved in this study were staffed by an in-house intensivist and fellow at night. This level of expertise may not be available in other ICU settings. Also, this particular institution adopted an aggressive weaning protocol that included daily sedation vacations and spontaneous breathing trials. These protocols were conducted by the respiratory therapists on a regular basis with physician consultation. In hospitals where similar staffing and protocols are not in place, it may be difficult to translate the results of this study to clinical practice.
Although this study reveals that nighttime extubations were not associated with increased risk of reintubation, LOS, or mortality, the application of this study to a general ICU population may be a stretch, unless the specific ICU reflects staffing and patient population similar to those in this study. Until there are more studies that examine this issue in a variety of ICU populations, there is insufficient evidence to support or refute the general safety of nighttime extubations in the ICU. Therefore, it is responsible to continue to be thoughtful regarding nighttime extubations in the ICU, always aware of the specific clinical situation and supportive staff in place.
