Maybe I need some reassurance...

Posted

I was wondering if anyone else could share a similar story. I'm about to enter my second year of nursing in a smallish level 3 NICU (26 bed, no surgeries or ECMO). We haven't had a lot of vented patients since i've come off orientation in June but I had the opportunity the last 3 days to take care of a micropreemie (800 gm 25 weeker). i really enjoyed the experience and learned a lot. Two of the three nights I had him, he self-extubated. I'm still trying to understand this. He was positioned prone on a pony both times, ETT tape secure, head was sandbagged to prevent too much movement, etc...sats started dropping, not having any spontaneous breaths on the vent (low tidal volumes)...so I suctioned, called for RT, we put on CO2 detector, no change...listened for BS bilaterally...pretty much was clear he was extubated. Now when you looked at the CXR you can see the ET tube and it's position near the carina (one xray it was a little high and our reintubation was T3), and it's definitely apparent in a tiny baby like this there is not a lot of room between intubated and extubated. I somehow feel responsible for this happening...I was not at the bedside when it happened (I mean I wasn't in there doing cares or anything) but is there anything I could have done to prevent it? Someone told me we have a day charge nurse that considers it "an incident report" when this happens so now i'm questioning myself (*note this was just info told to me by someone else, no incident report was written). Anyone have any advice for me on this?

SteveNNP, MSN, NP

Specializes in Neonatal ICU (Cardiothoracic). Has 9 years experience. 2 Articles; 2,512 Posts

Who knows whose fault it was...the baby could've flexed his neck, causing the tube to come out of the trachea.

IMHO, a baby who frequently self extubates shouldn't be placed prone unless sedated. It's too easy to extubate when they are so tiny, and a fraction of a centimeter of tube movement means you're out.

PS, I'm biased. Sandbags are a "band-aid cure" for not managing pain and sedation. Too many physicians think that a baby who can't move under a sandbag is a baby who's comfortable. IMHO if they are moving that much and are that small, they are probably in pain and need more than being restrained.

RNin2007

RNin2007

513 Posts

Yeah, I was told by dayshift RN in report "he does much better prone" as far as saturations and comfort level. He didn't seem to be overly active but maybe he did need some sedation. Thanks Steve.

kangarooyou

kangarooyou

23 Posts

Hi :)

As far as the "incident report" issue...we have to file them when we have this issue too...matter of fact had this happen to me for the first time a month ago...(kid was not in kangaroo, as it of course, has never happend during KC), and it is listed under "self extubation"...because of the need to re intubate, which could cause trauma, and you do have vital sign changes...it is an incident...depends on your hosp policy. We write incident reports for so much stuff!

As far as it being your fault...please do not blame yourself....it happens...to all of us, and it sure makes you feel aweful....but like Steve said, just a teeny, tiny movement could extubate. Was your tubing propped on something that could have moved the tube as it moved? Or maybe your tube needed to be propped when prone...I love putting my tiny ones on their tummies...they love it too...but I noticed that you have to be really careful with the position of the tubing, kinks happen easily too. Also...maybe was not extubated...was there a clog in the ET tube when you removed it? sometimes those excretions clog up the tube...or the baby "clamps" down...I had this happen to me, we used albuterol right into the ETT, to open the lungs up...depends on your docs and your policy if this is allowed.

Dont feel bad, we all have been there...keep learning, and growing...and talking to your fellow NICU ers :)

take care,

Christine

RNin2007

RNin2007

513 Posts

Hi :)

As far as the "incident report" issue...we have to file them when we have this issue too...matter of fact had this happen to me for the first time a month ago...(kid was not in kangaroo, as it of course, has never happend during KC), and it is listed under "self extubation"...because of the need to re intubate, which could cause trauma, and you do have vital sign changes...it is an incident...depends on your hosp policy. We write incident reports for so much stuff!

As far as it being your fault...please do not blame yourself....it happens...to all of us, and it sure makes you feel aweful....but like Steve said, just a teeny, tiny movement could extubate. Was your tubing propped on something that could have moved the tube as it moved? Or maybe your tube needed to be propped when prone...I love putting my tiny ones on their tummies...they love it too...but I noticed that you have to be really careful with the position of the tubing, kinks happen easily too. Also...maybe was not extubated...was there a clog in the ET tube when you removed it? sometimes those excretions clog up the tube...or the baby "clamps" down...I had this happen to me, we used albuterol right into the ETT, to open the lungs up...depends on your docs and your policy if this is allowed.

Dont feel bad, we all have been there...keep learning, and growing...and talking to your fellow NICU ers :)

take care,

Christine

I'm learning right here reading these replies...this is so helpful to me. Appreciate all of you who are chiming in on this, because my level 3 orientation and number of vented patients i've had has been very limited. The tubing was propped on another sandbag and I always take a look at my patient when sats drop to make sure whatever support they are on (CPAP, NC, etc.) is correctly positioned...but its a bit more of a mystery with an ETT and a baby this small. There was no clot in the tube, which is what I expected since we were suctioning thick secretions all night long. I did watch the tube for kinks and tried to be sure that the tube was in optimal positioning while he was prone. The only other micro i've cared for (while I was on orientation) was so sick that she didn't move really...which also leads me to really concur with what Steve said about the baby possibly needing something for pain ...sedation. I'm really learning still, and it really did make me feel bad to have to reintubate my patient two days in a row, especially when he had a blood tinged residual which im sure was from the trauma of being re-intubated :(.

Again thanks for your reply.

UTVOL3

UTVOL3

Specializes in NICU, adult med-tele. Has 6 years experience. 281 Posts

PS, I'm biased. Sandbags are a "band-aid cure" for not managing pain and sedation. Too many physicians think that a baby who can't move under a sandbag is a baby who's comfortable. IMHO if they are moving that much and are that small, they are probably in pain and need more than being restrained.

Yes!

Of course they can't move their darn heads. They only weigh 400gm and someone has a beanbag laying on top of it!:nono:

NICURN29

NICURN29

Specializes in NICU. Has 11 years experience. 188 Posts

I am glad that we don't have to write up incident reports for self-extubations! It doesn't happen to us all that often, but it does happen...I think it is, in some ways, part of working in the NICU.

I get frustrated when pain control is not optimal, and I think that often contributes to self-extubations. Of course a baby who is intubated is in pain. And if he is on the oscillator or jet? Even more in pain! We usually start out with a fentanyl drip, but we wean on that fairly quickly. And then we may get some PRN fentanyl or versed...but not always.

We do usually have babies nasally intubated, which I think cuts down on the risk. I know not everyone agrees, but I find a nasal tube much more stable. And otherwise, it's careful positioning, knowledge that comes with time.

I only took care of one intubated baby for one night on my orientation (I have been in the NICU for about two years), and for a long time, I was in complete panic mode for the entire night whenever I had a really sick kid. Now, it has become much more routine for me, and I handle it a lot better than I used to (and even enjoy taking care of sick kids, which I never thought would happen). With time, you will get there as well!

3yrDiploma

3yrDiploma

Specializes in NICU. Has 29 years experience. 49 Posts

We have a few nurses that can't seem to get thru their shift without having to re-intubate SOMEONE !! You guys that have compassionate enough docs that will give something for pain and sedation are very lucky. The ONLY time we can give anything for pain is for our post-ops. We do sedate with Fentnyl for our PPHN.........it is almost embarrasing

texas2007

texas2007, BSN, RN

Specializes in NICU. Has 2 years experience. 281 Posts

well if it makes you feel any better, one night i got report and found out both of my patients (800 grams each) had self extubated themselves that day. well one nec'd out, coded and died on my shift and the other self extubated/coded again while i was taking my break. what a night... i just wanted to go home.

moral of the story: it happens!!

our unit is poor about pain relief. rarely do PRN's unless you've been weaned from a drip, which is reserved for those with really bad blood gasses, or really wild or post op. this is kinda going off topic but just to make my point, last night i had this 7 mo kid who's been on a morphine/versed drip forever. so his versed drip was turned off last week and is on PO ativan .05 mg/kg. then they took his morphine drip from 50 mcgs/kg/min drip to 25 in one day and then cut if off the next day, with only PO .05 mg/kg q3 PRN and some methadone expected to relieve him. that was a GREAT night...

RNin2007

RNin2007

513 Posts

well if it makes you feel any better, one night i got report and found out both of my patients (800 grams each) had self extubated themselves that day. well one nec'd out, coded and died on my shift and the other self extubated/coded again while i was taking my break. what a night... i just wanted to go home.

moral of the story: it happens!!

our unit is poor about pain relief. rarely do PRN's unless you've been weaned from a drip, which is reserved for those with really bad blood gasses, or really wild or post op. this is kinda going off topic but just to make my point, last night i had this 7 mo kid who's been on a morphine/versed drip forever. so his versed drip was turned off last week and is on PO ativan .05 mg/kg. then they took his morphine drip from 50 mcgs/kg/min drip to 25 in one day and then cut if off the next day, with only PO .05 mg/kg q3 PRN and some methadone expected to relieve him. that was a GREAT night...

Wow, you had two vented patients that night? When we have a vented patient it's a 1 on 1 assignment (however we are a small 26 bed unit). That sounds like it was a rough night, I can only imagine. I am really starting to enjoy level 3, and learned a lot taking care of this baby. I try to ask for as many patients like this that come in since lately they are few and far between.

texas2007

texas2007, BSN, RN

Specializes in NICU. Has 2 years experience. 281 Posts

Wow, you had two vented patients that night? When we have a vented patient it's a 1 on 1 assignment (however we are a small 26 bed unit). That sounds like it was a rough night, I can only imagine. I am really starting to enjoy level 3, and learned a lot taking care of this baby. I try to ask for as many patients like this that come in since lately they are few and far between.

Oh yeah it's routine to have 2 vents. It's not rare to have 2 stable vents and admit a 3rd, but that's only happened to me once or twice. Another variation is to have a vent and 2 cpaps/cannulas/room air combo. It's rare to have 1:1 assignments, it's either dialysis or a really really really sick unstable kid that requires lots of blood gasses, blood transfusions, with 10 drips going. But even then, most kids that are expected to pass aren't even made 1:1 so it can be a challenge doing good death care along with managing your other (often screaming) patient. We simply don't have the staff to have every vent 1:1, and...don't you get bored? I'll get bored with 2 vents if nothing is really going on with them.

RNin2007

RNin2007

513 Posts

Oh yeah it's routine to have 2 vents. It's not rare to have 2 stable vents and admit a 3rd, but that's only happened to me once or twice. Another variation is to have a vent and 2 cpaps/cannulas/room air combo. It's rare to have 1:1 assignments, it's either dialysis or a really really really sick unstable kid that requires lots of blood gasses, blood transfusions, with 10 drips going. But even then, most kids that are expected to pass aren't even made 1:1 so it can be a challenge doing good death care along with managing your other (often screaming) patient. We simply don't have the staff to have every vent 1:1, and...don't you get bored? I'll get bored with 2 vents if nothing is really going on with them.

Definitely get bored if I have a stable vent patient and nothing is going on with them.

:grn:

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