Should you extubate during night ? Yes, if you are there!

Gershengorn et al published in JAMA a very large retrospective cohort study of 97 844 patients from 165 US ICUs who participate in Project Impact from October 1, 2000, to March 29, 2009.

Authors created  4518 propensity-matched pairs of patients with less than 12 hours of Mechanical ventilation and 5761 propensity-matched pairs of patients with mechanical ventilation of more than 12 hours. 

Night time extubations were associated with high rate of reintubation in both categories, but showed increased mortality in patients who were on MV for more than 12 hours.

In another study published by Tischenkel BR et el in 2014, 2240 patients were extubated , 1555 were extubated during the day and 685 were extubated at night. There was no difference in the outcome in terms of re-intubation or mortality. This was a retrospective cohort study performed at 2 hospitals within a tertiary academic medical center included all adult intensive care unit (ICU) patients extubated between July 01, 2009 and May 31, 2011.

Some important points

Study by Gershengorn was done on patients from 2000 to 2009, after which ventilation strategy has changed significantly. Patients were excluded if they died, received a tracheostomy, or had any limitations placed on their care (eg, orders for no cardiopulmonary resuscitation and/or to withhold or withdraw therapy) before a first extubation attempt. There was not a good way to differentiate between planned vs unplanned extubations (which are known to have bad outcomes). It is not clear if the order to extubate was given by an intensivist, though intensivists were present in 26% of the patients.

Study by  Tischenkel BR excluded patients who were extubated for withdrawal of care. There was in house fellow and intensivist available. 52% of patients had cardiac surgery.

Proposed reasons for bad outcome with night time extubations include

  1. Fewer and less trained staff
  2. Tired and less attentive staff
  3. Natural diurnal variation of diseases to affect during night time.. CHF, arrhythmia etc
  4. Question of presence of intensivist during night.

Bottomline

Night time extubations most likely increase bad outcome, however, if the patient is post surgical its okay to extubate in the night. I will go even further, if, an intensivist has evaluated the patient and crossed the Ts and dotted the Is, It would be okay to extubate in the night.