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Department: Critical Issues

Consider liberalizing restraint use in intubated patients with COVID-19

Kinthala, Sudhakar MD; Porter, Burdett MD; Saththasivam, Poovendran MD

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doi: 10.1097/01.CCN.0000668580.03172.92
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The current coronavirus disease 2019 (COVID-19) pandemic is challenging the healthcare workforce at every level. Critically ill patients with COVID-19 frequently require endotracheal intubation and mechanical ventilatory support as part of the necessary management of acute respiratory distress syndrome (ARDS) associated with the disease. Many of these patients also require prolonged mechanical ventilation.1

A study by Gueret and colleagues in a medical ICU found a self-extubation rate of 1.3 per 100 days of mechanical ventilation.2 The presence of agitation is associated with increased risk of self-extubation.3 The need for reintubation is associated with a high rate of pulmonary complications, such as aspiration, ventilator-associated pneumonia, prolonged duration of mechanical ventilation, and increased hospital stay.4

Self-extubation by patients with COVID-19 poses a significant hazard to healthcare workers, because person-to-person spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is thought to occur mainly via respiratory droplets.5,6 Reintubation would undoubtedly increase the consumption of personal protective equipment (PPE) and other resources when many hospitals are facing critical supply shortages. This situation raises an important question. Should clinicians more liberally use restraints in patients with COVID-19 who require ventilatory support in order to minimize the risk of self-extubation?

Applying physical restraints to promote healing in the ICU is a topic of ethical debate. Some studies have shown physical restraints can lead to more agitation and delirium in mechanically ventilated patients in the ICU.7 However, restraints have also effectively prevented accidental removal of endotracheal tubes and other essential indwelling devices.8 A patient who self-extubates is theoretically in danger of aerosolizing the virus, which potentially increases critical care nurses' and other healthcare professionals' risk of infection. The reintubation process can also put clinicians at risk for infection.

Patients with COVID-19 who require mechanical ventilation are also unique in the sense that they necessitate strict transmission-based precautions. Restraining an intubated patient without COVID-19 can cause emotional distress for family members at the bedside; however, this certainly is not the case with intubated patients with COVID-19, as visitors are not permitted due to the risk of infection. Critically ill patients usually have a low patient-nurse ratio; however, that ratio is unrealistic given the shortages of nurses during this pandemic. This lack of nursing staff may also increase the odds of self-extubation.

Liberal use of physical restraints within the parameters of each institution's policies and procedures may help decrease the risk of self-extubation, potentially improving patient outcomes, increasing the safety of healthcare personnel, and conserving PPE.

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3. Freeman S, Yorke J, Dark P. Patient agitation and its management in adult critical care: a integrative review and narrative synthesis. J Clin Nurs. 2018;27(7-8):e1284–e1308.
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5. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). 2020.
6. Coronavirus disease 2019 (COVID-19): questions and answers. UpToDate. 2020.
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8. Perren A, Corbella D, Iapichino E, et al. Physical restraint in the ICU: does it prevent device removal. Minerva Anestesiol. 2015;81(10):1086–1095.
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