Characteristics and outcomes of unplanned extubation in adult ICU: two-year retrospective observational cohort study.

Abstract

Background: Unplanned extubation (UE) is a critical adverse event in the intensive care unit associated with significant morbidity. This study aimed to evaluate the incidence, clinical characteristics, and 28-day mortality predictors of UE in a large tertiary care setting. Methods: A two-year retrospective descriptive study was conducted in a 120-bed closed ICU in Riyadh, Saudi Arabia, between January 2024 and December 2025. All adult patients undergoing mechanical ventilation who experienced UE were included. Data on demographics, airway management, staffing ratios, and clinical outcomes were analyzed. Results: Out of 4,054 mechanically ventilated patients, 226 experienced UE, resulting in an incidence rate of 0.52 per 100 ventilator days. The majority of events were self-extubations (77.4%) and occurred during the day shift (61.5%). The median (IQR) distance from the endotracheal tube (ETT) tip to the carina was 6.2 (4.6 – 7.8) cm, indicating relatively superficial positioning. Re-intubation was required in 57.5% of cases within 48 hours. The overall 28-day mortality rate was 22.6%. Accidental extubation patients were more frequently reintubated (90% vs. 48%) and had a higher 28-day mortality rate (44% vs. 16.6%). Subgroup analysis revealed that younger age (≤39 years; RR 0.35), occurrence during the day shift (RR 0.56), successful avoidance of re-intubation (RR 5.54 if reintubation required), and self extubation (RR 2.66 if accidental) were significantly associated with lower mortality risk. Conclusion: While the incidence of UE was relatively low, the high rate of self-extubation during peak activity hours (day shifts) and the superficial positioning of ETTs suggest a need for enhanced tube fixation and vigilance during sedation holidays. Younger age, morning shift occurrence, avoiding the need for re-intubation, and self-extubation are key factors associated with improved survival following an unplanned extubation event.