Bundle para redução das extubações não planejadas em unidade de terapia intensiva neonatal : uma experiência
Arquivos
Data
2017-10-02
Autores
Ferraz, Priscila Cristina João 
Orientadores
Barros, Marina Carvalho de Moraes
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: A ventilação pulmonar mecânica apesar de reduzir a mortalidade neonatal apresenta complicações, como a extubação não planejada (ENP). Caracterizada como a retirada não programada da cânula traqueal (COT), a taxa de ENP é um indicador de qualidade da assistência neonatal. Objetivo: Avaliar a efetividade de um bundle na redução de ENP em recém-nascidos (RN) ventilados, em UTI Neonatal (UTIN). Verificar os fatores associados à ENP. Método: Estudo de intervenção com grupo controle histórico realizado em UTIN, nos períodos de junho/2014-maio/2015, Período I (PI) e setembro/2015-agosto/2016, Período II (PII). Foram incluídos RN ventilados e excluídos os traqueostomizados ou com malformação de face. O bundle (novo modelo de fixação da COT, treinamento da equipe - posicionamento do RN e do circuito e manipulação do RN, identificação do RN de risco para ENP e debriefing após os episódios de ENP) foi implementado entre PI e PII. Foram comparadas as causas de ENP entre PI e PII. As taxas de ENP/100 RN ventilados-dia foram comparadas entre os períodos para toda a amostra, de acordo com o peso ao nascer (PN) (<ou> 1500g) e conforme a causa da ENP, acidental ou por troca de COT. Avaliou-se a associação entre fatores relativos ao RN e à assistência e a ENP, considerando-se apenas o primeiro episodio de ENP de cada RN, por regressão logística. Resultados: Foram avaliadas 231 intubações em 120 RN no PI (Idade gestacional (IG) 33,6±4,7sem; PN 2020±929g) e 212 intubações em 131 RN no PII (IG 34,2±4,7sem; PN 2080±997g). ENP ocorreu em 19,9% e 14,6% das intubações, em PI e PII. ENP acidentais e por troca de COT foram observadas em 58,7% e 41,3% das ENP no PI e em 51,6% e 48,4% no PII. Não se observou diferença na taxa de ENP/100 RN ventilados-dia entre PI e PII para toda a amostra (2,99±1,40 vs 2,71±1,38; p=0,629), para os RN<1500g (2,49±1,83 vs 3,50±3,87; p=0,421), RN>1500g (4,73±4,03 vs 3,42±3,49; p=0,405), ENP acidentais (1,69±1,07 vs 1,40±1,16; p=0,542) ou ENP por troca de COT (3,15±3,17 vs3,71±4,84; p=0,742). O maior PN associou-se a menor chance de ENP em todos os pacientes e a maior IG associou-se à menor chance de ENP por troca de COT. O maior escore de gravidade SNAPPE-II associou-se a maior chance de ENP em todos os neonatos, independentemente do PN, e às ENP acidentais ou por troca de COT. O período diurno associou-se à menor chance de ENP em todos os recém-nascidos e a aumento na chance de ENP, quando se avaliou os RN>1500g ou quando se considerou as ENP por troca de COT. Conclusões: O bundle implementado não reduziu as ENP em RN ventilados em UTIN, sendo as ENP acidentais e por troca de COT igualmente distribuídas entre os dois períodos. A maior IG e o maior PN associaram-se a menor chance de ENP e o maior escore de gravidade, a maior chance de ENP, entre os RN ventilados. O período diurno associou-se a menor chance de ENP, porém quando se avaliou os RN>1500g e as ENP por troca de COT, ele se associou a maior chance de ENP.
Introduction: Mechanical lung ventilation, despite reducing neonatal mortality, presents complications, such as unplanned extubation (UE). Characterized as an unplanned withdrawal of the endotracheal tube (ETT), the UE rate is an indicator of neonatal care quality. Objective: To evaluate the effectiveness of a bundle in the reduction of UE in ventilated newborns (NB) in the neonatal intensive care unit (NICU). Verify the factors associated to the UE. Method: Study of intervention with a historical control group performed at the NICU between June/2014-May/2015, Period I (PI) and September/2015-August/2016, Period II (PII). Ventilated NB were included and those tracheostomized or with face malformations were excluded. The package (new ETT fixation model, team training - NB and circuit positioning and NB manipulation, NB risk identification for UE and debriefing after UE episodes) was implemented between PI and PII. The causes of UE were compared between PI and PII. Rates of UE/100 day-ventilated NB were compared between the periods for the entire sample, according to birth weight (BW) (<or> 1500g) and according to the cause of UE, accidental or by exchange of ETT. Association between the factors related to NB and to the care, and UE, considering only the first UE episode of each NB, were analyzed by logistic regression. Results: A total of 231 intubations were performed in 120 infants at PI (gestational age (GA) 33.6±4.7w, BW 2020±929g) and 212 intubations in 131 infants at the PII (GA 34.2±4.7w, BW 2080±997g). UE occurred in 19.9% and 14.6% of intubations, in PI and PII. Accidental and by exchange of ETT UE were observed in 58.7% and 41.3% of UE in the PI and in 51.6% and 48.4% in the PII. There was no difference in the rate of UE/100 ventilated-day NB between PI and PII for the whole sample (2.99±1.40 vs. 2.71±1.38; p=0.629) for the NB<1500g (2.49±1.83 vs. 3.50±3.87; p=0.421), NB>1500 g (4.73±4.03 vs. 3.42±3.49; p=0.405), accidental UE (1.69±1.07 vs. 1.40±1.16; p=0.542) or UE by exchange of ETT (3.15±3.17 vs. 3.71±4.84; p=0.742). The higher BW was associated with a lower chance of UE in all patients, and the higher GA was associated with a lower chance of UE by ETT exchange. The higher SNAPPE-II severity score was associated with a greater chance of UE in all neonates, regardless of BW, and to accidental and by change of ETT UE. The daytime period was associated with a lower chance of UE in all newborns and with a greater chance of UE in NB>1500g or when UE by exchange of ETT were evaluated. Conclusion: The implemented package did not reduce the ENP in NB ventilated in NICU, being the accidental and by exchange of ETT UE equally distributed between the two periods. The higher GA and the higher BW were associated with a lower chance of UE, and the higher severity score was associated to a greater chance of UE among ventilated NB. The daytime period was associated with a lower chance of UE, but when NB>1500g and the UE by exchange of ETT were evaluated, it was associated with a greater chance of UE.
Introduction: Mechanical lung ventilation, despite reducing neonatal mortality, presents complications, such as unplanned extubation (UE). Characterized as an unplanned withdrawal of the endotracheal tube (ETT), the UE rate is an indicator of neonatal care quality. Objective: To evaluate the effectiveness of a bundle in the reduction of UE in ventilated newborns (NB) in the neonatal intensive care unit (NICU). Verify the factors associated to the UE. Method: Study of intervention with a historical control group performed at the NICU between June/2014-May/2015, Period I (PI) and September/2015-August/2016, Period II (PII). Ventilated NB were included and those tracheostomized or with face malformations were excluded. The package (new ETT fixation model, team training - NB and circuit positioning and NB manipulation, NB risk identification for UE and debriefing after UE episodes) was implemented between PI and PII. The causes of UE were compared between PI and PII. Rates of UE/100 day-ventilated NB were compared between the periods for the entire sample, according to birth weight (BW) (<or> 1500g) and according to the cause of UE, accidental or by exchange of ETT. Association between the factors related to NB and to the care, and UE, considering only the first UE episode of each NB, were analyzed by logistic regression. Results: A total of 231 intubations were performed in 120 infants at PI (gestational age (GA) 33.6±4.7w, BW 2020±929g) and 212 intubations in 131 infants at the PII (GA 34.2±4.7w, BW 2080±997g). UE occurred in 19.9% and 14.6% of intubations, in PI and PII. Accidental and by exchange of ETT UE were observed in 58.7% and 41.3% of UE in the PI and in 51.6% and 48.4% in the PII. There was no difference in the rate of UE/100 ventilated-day NB between PI and PII for the whole sample (2.99±1.40 vs. 2.71±1.38; p=0.629) for the NB<1500g (2.49±1.83 vs. 3.50±3.87; p=0.421), NB>1500 g (4.73±4.03 vs. 3.42±3.49; p=0.405), accidental UE (1.69±1.07 vs. 1.40±1.16; p=0.542) or UE by exchange of ETT (3.15±3.17 vs. 3.71±4.84; p=0.742). The higher BW was associated with a lower chance of UE in all patients, and the higher GA was associated with a lower chance of UE by ETT exchange. The higher SNAPPE-II severity score was associated with a greater chance of UE in all neonates, regardless of BW, and to accidental and by change of ETT UE. The daytime period was associated with a lower chance of UE in all newborns and with a greater chance of UE in NB>1500g or when UE by exchange of ETT were evaluated. Conclusion: The implemented package did not reduce the ENP in NB ventilated in NICU, being the accidental and by exchange of ETT UE equally distributed between the two periods. The higher GA and the higher BW were associated with a lower chance of UE, and the higher severity score was associated to a greater chance of UE among ventilated NB. The daytime period was associated with a lower chance of UE, but when NB>1500g and the UE by exchange of ETT were evaluated, it was associated with a greater chance of UE.
Descrição
Citação
JOÃO, Priscila Cristina. Bundle para redução das extubações não planejadas em unidade de terapia intensiva neonatal : uma experiência. São Paulo, 2017. [150] p. Dissertação (Mestrado em Pediatria e ciências aplicadas à pediatria) - Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, 2017.