Challenging Convention: Daytime Versus Nighttime Extubation in the Pediatric ICU

BACKGROUND: The majority of pediatric extubations occur during day shift hours. There is a time-dependent relationship between mechanical ventilation duration and complications. It is not known if extubation shift (day vs night) correlates with pediatric extubation outcomes. Pediatric ventilation duration may be unnecessarily prolonged if extubation is routinely delayed until day shift hours.

METHODS: We hypothesized that extubation failure would not correlate with shift of extubation and that ventilation duration at first extubation and that length of stay in the pediatric ICU (PICU) would be shorter for children extubated at night. This was a retrospective cohort study within one tertiary care, 24-bed, academic PICU.

RESULTS: 582 ventilation encounters were included, representing 517 unique subjects. Status epilepticus was a more common diagnosis among night shift extubations (P = .005), whereas surgical airway conditions were more common among day shift extubations (P = .02). Mechanical ventilation duration at first extubation (37.6 vs 62.5 h, P < .001) and length of stay in the PICU (2.8 vs 4.5 d, P < .001) were shorter for night shift extubations. The extubation failure rate was 10.3% for day shift and 8.1% for night shift (P = .40). Logistic regression modeling at the level of the unique subject indicated that extubation shift was not associated with extubation failure (P = .44). The majority of re-intubation events occurred on the shift opposite of extubation. There was no difference in complications according to shift of re-intubation (P = .72).

CONCLUSIONS: Extubation failure was not independently associated with extubation shift in this single-center study. Ventilation liberation should be considered at the first opportunity dictated by clinical data and patient-specific factors rather than by the time of day at centers with similar resources.