NICU- accidental extubation

[nicu1_RN]

Hi all. I am an RN at a level III NICU. Our unit has been exploring new methods of securing ETTs. The other night, I was turning a patient's head and the baby extubated. I felt so horrible. This is the first time ever happening to me. I have always thought my method of turning was very secure. I know I had the tube secure. If this has ever happened to you, could you give me any advice or words of encouragement?

[llg, PhD, RN]

Only to reinforce to you that it is a common problem. Yes, it's natural that you feel bad. It's like making a med error. We try to "never let it happen to us" ... but it happens sometimes.

Review your actions. Talk with any mentors/friends you have made in your unit. Look for ways to improve. etc. Then forgive yourself and move on. That's all you can do. Things like that happen to all of us. It's a part of practice, a part of living with the risks of actually doing something rather than just sitting on the sidelines and watching.

[Coffee Nurse, BSN, RN]

Maybe the new methods of securing the ETT aren't that great? What has your unit been using, and what are you experimenting with now?

[SteveNNP, MSN, NP]

My unit uses exclusively nasal intubation with a complicated taping method that involves pink tape, suture material, and a suction catheter tube. Don't ask. All I know is that it is the most secure way I've ever seen a tube taped.

When we do get a transport with an ETT, we usually change it out to an NTT, or replace the tape with a NeoBar.

[aerorunner80, ADN, BSN, MSN, APRN]

My unit uses exclusively nasal intubation with a complicated taping method that involves pink tape, suture material, and a suction catheter tube. Don't ask. All I know is that it is the most secure way I've ever seen a tube taped.

When we do get a transport with an ETT, we usually change it out to an NTT, or replace the tape with a NeoBar.

Steve,

Do you have any more information on using NTT tubes? Our unit used to suture our tubes into the tape but have stopped. We haven't had any accidental extubations yet, but I'm sure our time is coming.

I'm just curious about the NTT's though. I've never heard of them or seen them.

Thanks!

[nicu1_RN]

Our NICU uses only ETTs. We have never experimented with NTTs. We have done a study with the pink tape method (Which is basically our original tape method with a layer of pink tape on top), Neobars, and the Portex tube holder. The reason for this trial study was in hopes to decrease the number of accidental extubations we have. I would love to present our NICU with some information regarding other ways of tube security to keep our patients safe.

[SteveNNP, MSN, NP]

Steve,

Do you have any more information on using NTT tubes? Our unit used to suture our tubes into the tape but have stopped. We haven't had any accidental extubations yet, but I'm sure our time is coming.

I'm just curious about the NTT's though. I've never heard of them or seen them.

Thanks!

If you do a cochrane neonatal lit review, the research basically holds 50:50 for ETT vs. NTT. With ETTs, you get palatal/lip grooving, and subsequent feeding issues. With NTTs, you can get nasal breakdown/irritation.

I don't know how other units tape their NTT, but we prep the skin in a mustache-pattern, lay a barrier layer of pink tape, then wrap suture in a surgical knot around the NTT at the appropriate measurement. We then put the ends of the suture through a piece of cut 8fr suction catheter, and knot the two loose threads at each end. We then place a long partially backed strip of tape behind the baby's neck, pull each end through each end of the looped suture, and then double it back onto the strip of tape coming from behind the baby's neck. Finally we split a piece of pink tape, wrap the sutured area of the NTT to protect the nare from the suture irritation, then stick it to the bridge of the baby's nose.

It sounds complicated and confusing, but it's a basic part of orientation. We rarely have self extubations here...and our nare irritation/breakdown is entirely dependent on the care taken when securing the tube initially.

[prmenrs, RN]

It is extremely easy to extubate a baby, so don't beat yourself up over it. When you do your 1st assessment, check the tube. If you think it might be loosening, have an RT check it w/you, and do a planned tape change if necessary.

Years ago, it was a lot more common to accidently extubate--sometimes the baby did it for you! Never trust 'em. (I've said that before!)

[cjcsoon2bnp, MSN, RN, NP]

If you do a cochrane neonatal lit review, the research basically holds 50:50 for ETT vs. NTT. With ETTs, you get palatal/lip grooving, and subsequent feeding issues. With NTTs, you can get nasal breakdown/irritation.

I don't know how other units tape their NTT, but we prep the skin in a mustache-pattern, lay a barrier layer of pink tape, then wrap suture in a surgical knot around the NTT at the appropriate measurement. We then put the ends of the suture through a piece of cut 8fr suction catheter, and knot the two loose threads at each end. We then place a long partially backed strip of tape behind the baby's neck, pull each end through each end of the looped suture, and then double it back onto the strip of tape coming from behind the baby's neck. Finally we split a piece of pink tape, wrap the sutured area of the NTT to protect the nare from the suture irritation, then stick it to the bridge of the baby's nose.

It sounds complicated and confusing, but it's a basic part of orientation. We rarely have self extubations here...and our nare irritation/breakdown is entirely dependent on the care taken when securing the tube initially.

Any chance that we might be able to see a photo of this (maybe on a training model or something) I'm just having a really hard time imagining this setup that you guys are using.

!Chris