Revisiting Unplanned Endotracheal Extubation and Disease Severity in Intensive Care Units

<div><p>Most reports regarding unplanned extubation (UE) are case-control studies with matching age and disease severity. To avoid diminishing differences in matched factors, this study with only matching duration of mechanical ventilation aimed to re-examine the risk factors and the factors governing outcomes of UE in intensive care units (ICUs). This case-control study was conducted on 1,775 subjects intubated for mechanical ventilation. Thirty-seven (2.1%) subjects with UE were identified, and 156 non-UE subjects were randomly selected as the control group. Demographic data, acute Physiological and Chronic Health Evaluation II (APACHE II) scores, and outcomes of UE were compared between the two groups. Logistic regression analysis was used to identify the risk factors of UE. Milder disease, younger age, and higher Glasgow Coma Scale (GCS) scores with more frequently being physically restrained (all p<0.05) were related to UE. Logistic regression revealed that APACHE II score (odds ratio (OR) 0.91, p<0.01), respiratory infection (OR 0.24, p<0.01), physical restraint (OR 5.36, p<0.001), and certain specific diseases (OR 3.79–5.62, p<0.05) were related to UE. The UE patients had a lower ICU mortality rate (p<0.01) and a trend of lower in-hospital mortality rate (p = 0.08). Cox regression analysis revealed that in-hospital mortality was associated with APACHE II score, age, shock, and oxygen used, all of which were co-linear, but not UE. The results showed that milder disease with higher GCS scores thereby requiring a higher use of physical restraints were related to UE. Disease severity but not UE was associated with in-hospital mortality.</p></div

Outcomes of unplanned extubation (UE).

<p>Abbreviations: ICU, intensive care unit; LOS, length of stay; MVS, mechanical ventilatory support; UE, unplanned extubation; NS, not significant</p><p>*Some missing data.</p><p>Outcomes of unplanned extubation (UE).</p

Mechanical ventilatory support (MVS) settings and cardiopulmonary responses before unplanned extubation (UE) (mean±SD).

<p>Abbreviations: no. AC, patient number used assisted control; no. PSV, patient number used pressure support ventilation; F_IO₂, fraction of inspired oxygen; PEEP, positive end-expiratory pressure; P_peak, peak airway pressure; I:E, inspiratory time and expiratory time ratio; BP, blood pressure; NS, not significant.</p><p>*Data measured on the corresponding day as the UE group with some missing data.</p><p>Mechanical ventilatory support (MVS) settings and cardiopulmonary responses before unplanned extubation (UE) (mean±SD).</p

Baseline characteristics and selected outcomes.

<p>Abbreviations: UE: unplanned extubation; APACHE II, Acute Physiological and Chronic Health Evaluation II; CVC, central venous catheter; Glasgow Coma Scale: score measured 1–7 days before and nearest the unplanned extubation; VEST^TM, a high frequency chest wall oscillator; NS, not significant.</p><p>^#Sedation use during this admission;</p><p>*Some missing data.</p><p>^†After excluding 17 patients with hypoxic encephalopathy in the non-UE group, the difference in Glasgow coma scores between the two groups remained significant (10±3.2 versus 7.5±3.3, p < .0001)</p><p>Baseline characteristics and selected outcomes.</p

Multiple logistic regression analysis for unplanned extubation.

<p>APACHE II: Acute Physiological And Chronic Health Evaluation II; CI: confidence interval</p><p>Multiple logistic regression analysis for unplanned extubation.</p

Flow Diagram.

<p>The frequencies of annual admission to intensive care units (ICUs), mechanical ventilatory support (MVS), and unplanned extubation (UE). Controls are the subjects without UE.</p

The Incidence of Japanese Encephalitis in Taiwan—A Population-Based Study

<div><p>Background</p><p>A mass Japanese encephalitis (JE) vaccination program targeting children was launched in Taiwan in 1968, and the number of pediatric JE cases substantially decreased thereafter. The aim of this study was to elucidate the long-term trend of JE incidence, and to investigate the age-specific seroprevalence of JE-neutralizing antibodies.</p><p>Methodology/Principal Findings</p><p>A total of 2,948 laboratory-confirmed JE cases that occurred between 1966 and 2012 were analyzed using a mandatory notification system managed by the Centers for Disease Control, Taiwan. A total of 6,594 randomly-sampled serum specimens obtained in a nationwide population-based survey in 2002 were analyzed to estimate the seroprevalence of JE-neutralizing antibodies in the general population. The average annual JE incidence rate of the group aged 30 years and older was 0.167 cases per 100,000 people between 2001 and 2012, which was higher than the 0.052 cases per 100,000 people among those aged under 30 years. These seroepidemiological findings indicate that the cohort born between 1963 and 1975, who generally received two or three doses of the vaccine and were administered the last booster dose more than 20 years ago, exhibited the lowest positive rate of JE-neutralizing antibodies (54%). The highest and second highest antibody rates were observed, respectively, in the oldest unvaccinated cohort (86%) and in the youngest cohort born between 1981 and 1986, who received four doses 10–15 years ago (74%).</p><p>Conclusion/Significance</p><p>Over the past decade, the main age group of the confirmed JE cases in Taiwan shifted from young children to adults over 30 years of age. People who were born between 1963 and 1975 exhibited the lowest seroprevalence of JE-neutralizing antibodies. Thus, the key issue for JE control in Taiwan is to reduce adult JE cases through a cost-effective analysis of various immunization strategies.</p></div

The cases number of Japanese Encephalitis and incidence rate in Taiwan during 1966–2012.

<p>The cases number of Japanese Encephalitis and incidence rate in Taiwan during 1966–2012.</p

Incidence rates and onset age distributions of Japanese Encephalitis confirmed cases in Taiwan, 2002–2012.

a<p>The incidence rate is the number of JE confirmed cases per 100,000 population at risk.</p>b<p>There were two JE confirmed cases have been received 1 dose of vaccine in 2008 and one has been vaccinated with 3 doses, in 2012.</p

Japanese Encephalitis incidence rates among different birth cohorts during 1966–2012.

<p>Japanese Encephalitis incidence rates among different birth cohorts during 1966–2012.</p