Unplanned extubation while on orientation

Specialties NICU

Published

I'm in my third week of orientation and just finished my third shift of caring for stable, intubated babies. While doing my assessment on one of my patients, after inline suctioning, his HR and sats dropped to the 30's. My preceptor had just gone to lunch and left me under the supervision of a podmate. I yelled for her help and she came in and immediately started bagging. Long story short, the baby got reintubated after several attempts and appeared to be stable immediately post procedure.

I was told repeatedly that it happens to everyone and to not feel bad, but I can't help but feel like crap and totally incompetent. It was my preceptor's first time EVER leaving an orientee by herself and she felt somewhat confident enough in me to do so momentarily. I really don't know what I could have done differently, as I wasn't trying to reposition him or anything. Externally, everything looked like it was in place and the tube didn't visibly come out. They did say the ETT must have been sitting very high because there was a 1.5 cm difference in depth with the new one. This baby was just over 1 kg and I believe it had been 2 weeks since the last chest X-ray. I keep trying to tell myself that this was the primary reason this happened, but whether that's entirely true or not, I'm not sure. I'm not very confident in positioning all the tubing.

What bothers me even more is that I had no idea what to do after calling the other nurse. I just stood there as everyone else took care of him. I didn't even know to start bagging him right away and observe for chest movement or listen for breath sounds. Although I don't complete NRP until next week, I feel like this is something I should have known, being a nurse. I'm completely paranoid that I'm going to do this again and my confidence has dropped to zero.

You guys are a tremendous resource and if anyone has any words of wisdom regarding these situations, I'd be eternally grateful. Thanks for letting me vent (no pun intended).

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Specializes in Critical Care.

I'm not a NICU nurse, but I am an ICU nurse, and I can tell you that these things happen. It WILL happen again to you. The important thing is that you learned from the situation-- now you know to immediately start bagging. It's normal to be shell shocked with these situations as a new nurse, nobody starts work knowing it all. Just learn from each situation and don't let it get your confidence!

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I'm not sure how you think you should have automatically known what to do. Orientation is there for a reason. They don't expect you to know everything! Now you know what to do if this happens again.

Cut yourself some slack. Take a deep breath. This will happen again. You are going to be fine!

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Specializes in NICU, PICU, PACU.

Don't feel bad...we all have that oh $&@" moment when a kid is being bad on you for the first time. You did the right thing by yelling for help and you saw the process of what to do. When it happens again, and it will lo, you now know what to look for. Our tubes can sit in funny positions and work up thru the tape after a while. Always check to see where the tube was originally placed and check it at least twice during your shift.

And it is still an oh $&@" moment when it happens to you even 30years later lol

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Specializes in NICU.

What I'll add is that the large majority of people don't have "natural" ICU instincts. Learning the warning signs and how one takes care of a patient in emergent situations is a learned skill. In my first year as a NICU RN I had a few patients extubate and a few PICC lines come out. However- after my "ICU instincts" kicked in, I never had another kid extubate (which is partially good luck I completely admit) nor had PICCs comes out inadvertently. There's no other way to explain it but that you just pick up on it as you go. You'll learn all about it in NRP and on orientation too, of course, but nothing trumps experience with this sort of thing.

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I will tell you what I told myself when I first started. I cannot promise to not make mistakes. They WILL happen. What I can promise is to learn from them and never make the same mistake twice. (I'm not even saying this instance was a mistake). You'll know what to do next time and soon you'll be the expert! Don't beat yourself up - careers are long and you'll be a better nurse because of things like these.

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Specializes in NICU.

Good for you for calling someone! I'm actually not even joking, is the sad thing. I hate working in a room with someone and glancing over to find them struggling with HR and sats in the toilet, with not even a peep to ask for help. Sometimes these things just happen, and the priority should always the baby's safety, no matter how many people you have to call in to make good on that.

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Specializes in NICU, PICU, PACU.

One of my peeves too! If you are sinking ask for help! If you don't know something, ask for help, if that baby is scaring the pants off you, ask for help!

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They did say the ETT must have been sitting very high because there was a 1.5 cm difference in depth with the new one. This baby was just over 1 kg and I believe it had been 2 weeks since the last chest X-ray. .

There's the problem. Most NICU's do a daily X-ray to check for ETT placement.

When the ETT is inserted, you need to check in report for the following:

1. The date of insertion.

2. The measurement documented at the lip.

Every time you assess the baby, you need to check to make sure you see the same mark. The first few times you turn a baby on a ventilator, move slow and have respiratory therapy right there in case something happens. It takes practice and I was shaking so bad the first time I did it I thought I was going to die. After a few times I was able to do it on my own.

Your #1 priority is watching the ETT tube and any lines to make sure that they do not pull. It takes practice.

I would get my baby "straight" and organized before I started turning. I also made sure I had a visual and within easy reach the mask and the CO2 detector.

Don't worry, the first time a baby extubated on me I literally froze with fear. They are very serious, it happens to everyone.

The fear comes from not knowing what to do. When you learn what to do, you will react to it like anything else that you fully understand.

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Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc.
They did say the ETT must have been sitting very high because there was a 1.5 cm difference in depth with the new one. This baby was just over 1 kg and I believe it had been 2 weeks since the last chest X-ray. I keep trying to tell myself that this was the primary reason this happened, but whether that's entirely true or not, I'm not sure).

Factoring that the tube was in correct placement on the previous X-ray 1.5 cm is a HUGE discrepancy in a baby. Just turning his head could have extubated him.

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Specializes in Neonatal ICU (Cardiothoracic).
There's the problem. Most NICU's do a daily X-ray to check for ETT placement.

I agree with everything else EXCEPT this quote. I sure hope this isn't the standard practice. At my facility (Level IV with ADC=75 including open hearts, ECMO, head cooling, and one-lung ventilation) and we rarely get daily CXR on stable intubated babies. Unless its a postop cardiac on a Lasix drip who we're trying to dry out, or a preemie who is acting funny. It's just not clinically indicated. And all these xrays add up to a significant dose of radiation by the time they go home.

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I agree with everything else EXCEPT this quote. I sure hope this isn't the standard practice. At my facility (Level IV with ADC=75 including open hearts, ECMO, head cooling, and one-lung ventilation) and we rarely get daily CXR on stable intubated babies. Unless its a postop cardiac on a Lasix drip who we're trying to dry out, or a preemie who is acting funny. It's just not clinically indicated. And all these xrays add up to a significant dose of radiation by the time they go home.

...and I agree that it does add up over time. However, that is what they do here. The rationale I was given is that many times that you can identify an ETT out of place before it gets to the point that the baby is having problems. It is a Level III.

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