Published online Jun 27, 2026. doi: 10.4240/wjgs.117179
Revised: February 12, 2026
Accepted: March 16, 2026
Published online: June 27, 2026
Processing time: 155 Days and 0.5 Hours
Unplanned extubation (UE) is a serious complication in patients with post-operative delirium (POD) after gastrointestinal surgery that significantly increases the risk of reintubation, ventilator-associated pneumonia, and mortality. Effective prevention strategies that integrate optimization of sedation-analgesia with structured nursing care are underexplored.
To determine an individualized sedation-analgesia strategy based on the risk of UE in patients with POD after gastrointestinal surgery.
Data from 118 patients with POD who required invasive mechanical ventilation for ≥ 24 hours in the intensive care unit, were retrospectively analyzed. Patients were assigned to an intervention group (n = 60) or a control group (n = 58). Pa
The intervention group had a lower incidence of UE and a composite endpoint of post-reintubation complications than the control group (P < 0.05). Durations of mechanical ventilation, intensive care unit stay, and delirium were significantly shorter in the intervention group (P < 0.05). Multivariate Cox regression analysis showed that increased daily fluctuation in the Richmond Agitation-Sedation Scale score, a higher frequency of extubation intention behaviors, insufficient reduction in interleukin-6, delayed intervention response time, high restraint usage, and low nursing assessment completion rates were independent risk factors for UE (P < 0.05).
A combined strategy to prevent UE in patients with POD is proposed, and it effectively reduced the incidence of UE and duration of hospitalization, improved nursing quality, and mitigated neuroinflammation.
Core Tip: In this study, a mechanism-oriented strategy (individualized sedation-analgesia + structured nursing) for unplanned extubation in patients with post-operative delirium after gastrointestinal surgery, is proposed. The incidence of unplanned extubation and duration of hospitalization were reduced, and nursing quality was improved, offering a safe model of prevention.
- Citation: Yu YH, Yang JJ. Comprehensive strategy for preventing unplanned extubation in patients with post-operative delirium after gastrointestinal surgery. World J Gastrointest Surg 2026; 18(6): 117179
- URL: https://www.wjgnet.com/1948-9366/full/v18/i6/117179.htm
- DOI: https://dx.doi.org/10.4240/wjgs.117179
Post-operative delirium (POD), a core phenotype of peri-operative neurocognitive disorders, presents in 30%-50% of patients undergoing major abdominal surgery[1]. Gastrointestinal surgery poses a high-risk pathological basis for POD due to extensive surgical trauma, severe visceral manipulation, significant post-operative pain, and disturbances to gut microbiota[2]. POD not only prolongs hospitalization and increases medical costs, but it is also associated with long-term cognitive decline and higher mortality[3]. Patients with agitated-type delirium often present with impaired conscious
Recent studies have suggested that POD is closely related to post-operative neuroinflammation, blood-brain barrier permeability, and neuronal injury[6]. Poorly controlled pain and inappropriate selection of sedatives can amplify this cascade. As the first line of bedside monitoring and intervention, nursing teams have a critical role in recognizing POD, assessing pain, restraint decision making, and airway safety management. However, previous studies have mainly focused on pharmacological or device interventions, with insufficient attention paid to the standardization of nursing procedures and their contributions to the prevention of UE. Therefore, in this study, a retrospective evaluation of the clinical effectiveness of an integrated management strategy in a real-world ICU setting was performed, from a nursing perspective, with the aim of reducing the incidence of UE. A total of 118 patients with POD after gastrointestinal surgery, were included, and the clinical outcomes and nursing quality indicators under different management strategies were compared to provide a reproducible and scalable model for the prevention of UE for this high-risk cohort.
The medical records of patients who underwent gastrointestinal surgery and who were admitted to the ICU of our hospital between January 2022 and November 2025, were retrospectively analyzed. Inclusion criteria: (1) Age ≥ 18 years; (2) Major open abdominal surgery, such as radical gastrectomy, pancreaticoduodenectomy, or colorectal cancer resection; (3) Diagnosed with POD by the confusion assessment method (CAM)-ICU within 72 hours post-operatively[7]; and (4) Invasive mechanical ventilation with an expected intubation duration ≥ 24 hours. Exclusion criteria: (1) Pre-operative Mini-Mental State Examination (MMSE) score < 24 or known dementia[8]; (2) Severe hepatic or renal dysfunction; (3) Allergy to dexmedetomidine or opioids; and (4) Concomitant traumatic brain injury or epilepsy. Based on these criteria, 118 patients were included and assigned to an intervention group (n = 60) or a control group (n = 58) using adaptive randomization. The groups were stratified based on whether the patients received a mechanism-oriented individualized sedation-anesthesia, combined airway management strategy (including standardized care procedures).
The control group received conventional sedation management, using propofol (0.5-4.0 mg/kg/hour) or midazolam (0.02-0.10 mg/kg/hour) continuous infusion to maintain the Richmond Agitation-Sedation Scale (RASS) score between -2 and -3. Nurses did not systematically perform standardized pain or delirium assessments. Endotracheal tube fixation was performed using a single medical tape placed horizontally across the cheek, and physical restraints were applied at the discretion of the bedside nurse.
The intervention group followed the 2018 Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption guidelines, combined with the “inflammation-delirium-agitation” cascade mechanism, to establish a dynamic closed-loop management pathway[9]. Post-operatively, all patients received a remifentanil-based analgesia regimen at 0.10 μg/kg/min, adjusted hourly according to the critical-care pain observation tool (CPOT) score: CPOT ≤ 2, maintain dose; CPOT 3-4, increase by 0.02 μg/kg/minute every 15 min until pain was controlled (CPOT ≤ 2), maximum dose 0.20 μg/kg/minute. Dexmedetomidine was used as the main sedative with a 1.0 μg/kg loading dose over 10 minutes, followed by 0.20-0.70 μg/kg/hour infusion. Sedation depth followed a “light, arousable” principle, target RASS score of -1 to 0. CAM-ICU assessments were performed twice-daily by certified nurses at 8:00 and 16:00, and sedation-analgesia doses were adjusted dynamically to ensure alignment with the delirium status.
Airway management included a standardized fixation protocol: Endotracheal tube secured with 3M Durapore™ tape in a cross “H” pattern, and additionally with a Thomas™ tube holder around the head, forming a “double fixation” structure. Physical restraints were applied only if the RASS score was ≥ +2 and there were clear extubation intention behaviors (e.g., repeated grasping of tube, raising the head, or attempting to sit up), observed via video monitoring or nursing records. Pre-restraint communication with patient/family was documented. Restraints were released every 2 hours to assess necessity, and local skin care and decompression were implemented.
Collection of general data: Data were collected within 2 hours of admission to the ICU, including age (years), sex, body mass index (kg/m2), primary disease and surgical type (radical gastrectomy/colorectal cancer resection/pancreatic cancer resection), duration of surgery (hour), and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. POD subtypes were classified based on twice-daily CAM-ICU assessments at 8:00 and 16:00 as hyperactive (RASS score ≥ +1) or mixed type (RASS score fluctuating between -3 and +2)[10]. Pre-operative cognitive function was evaluated using the MMSE score within 24 hours pre-surgery; patients scoring < 24 were excluded.
Clinical outcome indicators: (1) Primary outcome: Incidence of UE is the percentage of patients who removed the endotracheal tube by themselves, without meeting extubation criteria or without medical authorization; (2) Secondary outcomes: Duration of mechanical ventilation (from intubation to successful extubation), duration of ICU stay (from ICU admission to transfer), and duration of delirium (from first positive CAM-ICU assessment to 48 consecutive hours of negative assessments); (3) Safety endpoints: Composite complications after reintubation, including ventilator-associated pneumonia, acute laryngeal edema, tracheal stenosis, and all-cause mortality within 72 hours, post-UE; and (4) Drug-related adverse events: Including hypotension, bradycardia, and respiratory depression.
Nursing intervention response and restraint management indicators: All patients were monitored using a 24-hour infrared video system (approved by the ethics committee, individual consent waived). Two blinded investigators independently reviewed the recordings (Kappa 0.89). Extubation intention behaviors: Operationally defined as any of the following: (1) Repeated hand contact or grasping of the endotracheal tube ≥ 2 times/5 minutes; (2) Raising head causing tube displacement > 2 cm (based on tube markings); and (3) Actively lifting the torso > 30° and maintaining for > 10 seconds. Intervention response time: Time interval (second) from initial identification of extubation intention behavior to effective medical nursing intervention (e.g., verbal reassurance, sedation adjustment, or restraint). Physical restraint usage: Recorded use of soft wrist restraints (3M™ Soft Wrist Restraint), duration per episode (hour), and restraint-related skin injury (according to National Pressure Injury Advisory Panel/European Pressure Ulcer Advisory Panel 2019 pressure ulcer classification). CPOT assessment completion rate: ≥ 22 assessments in 24 hours (once per hour, excluding sleep periods) was considered to be compliant. CAM-ICU assessment completion rate: Twice-daily assessments (8:00 and 16:00) were considered to be compliant. Timely recognition of extubation intention behavior: Percentage of behaviors documented in nursing records within 5 min of occurrence. Pre-restraint communication documentation rate: Percentage of restraint events with documented communication between nurse and patient/family. Skin care implementation rate: Percentage of days with ≥ 2 documented episodes of cleaning, inspection, and pressure relief of restrained areas.
Sedation-delirium dynamic coupling: Mean daily fluctuation in the RASS score: Mean difference between daily maximum and minimum RASS scores. Frequency of extubation intention behaviors: The number of behaviors confirmed via a blinded 24-hour video review. Percentage of CAM-ICU positive days: Percentage of days in the ICU with positive delirium assessments.
Neuroinflammatory and biomarkers of brain injury: Venous blood samples were collected on post-operative day 1, day 3, and day 5, in the morning. Interleukin (IL)-6, pg/mL, measured by enzyme-linked immunosorbent assay), S100 calcium-binding protein β (S100β; pg/mL), and neuron-specific enolase (NSE; ng/mL, measured by chemiluminescence) levels were measured.
Statistical analyses were performed using SPSS version 26.0. Continuous variables were assessed for normality using the Shapiro-Wilk test and Q-Q plots. Normally distributed data are expressed as mean ± SD and were compared using independent-sample t-tests. Non-normally distributed data are presented as median (interquartile range) and were compared using the Mann-Whitney U test. Categorical variables are expressed as n (%) and compared using the χ2 test; Fisher’s exact test was used when the expected frequency was < 5. Repeated measures were analyzed using repeated-measures analysis of variance, reporting group effects, time effects, and group × time interaction P values. Cox proportional hazards regression analysis was used to identify independent risk factors for UE, expressed as hazard ratio (HR) with 95% confidence interval. Univariate and multivariate logistic regression analyses were performed to assess the predictive performance of key continuous variables, such as Self-Directed Care Index and frequency of extubation intention behaviors. All multivariate models were adjusted for age, APACHE II score, POD subtype, and other a priori confounding factors. Statistical significance was set at P < 0.05.
There were no significant differences between the intervention and control groups for age, sex distribution, body mass index, surgery type, duration of surgery, APACHE II score, POD subtype distribution, or pre-operative MMSE score (all P > 0.05; Table 1).
| Variable | Intervention group (n = 60) | Control group (n = 58) | t/χ2 | P value |
| Age (years) | 63.40 ± 8.70 | 64.10 ± 9.20 | 0.425 | 0.672 |
| Female/male | 26/34 | 30/30 | 0.290 | 0.590 |
| BMI (kg/m2) | 23.80 ± 3.10 | 24.20 ± 3.40 | 0.668 | 0.505 |
| Surgery type (gastric/colorectal/pancreatic) | 22/25/13 | 20/26/12 | 0.121 | 0.941 |
| Duration of surgery (hours) | 4.20 ± 1.10 | 4.40 ± 1.30 | 0.903 | 0.368 |
| APACHE II score | 16.30 ± 3.20 | 16.80 ± 3.50 | 0.810 | 0.419 |
| POD subtype (hyperactive/mixed) | 39/21 | 37/21 | 0.020 | 0.991 |
| Pre-operative MMSE score | 27.40 ± 1.80 | 27.10 ± 2.00 | 0.857 | 0.393 |
The incidence of UE was significantly lower in the intervention group (two patients, 3.33%) than in the control group (nine patients, 15.52%; P < 0.05). Durations of mechanical ventilation, stay in ICU, and delirium were significantly shorter in the intervention group (all P < 0.05). The composite endpoint of post-reintubation complications was not present in the intervention group, but there were five patients (8.62%) in the control group, with a statistically significant difference (P < 0.05). There were no significant differences in drug-related adverse events between the groups (P > 0.05; Table 2).
| Outcome | Intervention group (n = 60) | Control group (n = 58) | t/χ2 | P value |
| Incidence of UE | 2 (3.33) | 9 (15.52) | 0.028 | |
| Duration of mechanical ventilation (days) | 4.23 ± 1.62 | 6.14 ± 2.31 | 5.214 | 0.000 |
| Duration of stay in ICU (days) | 6.82 ± 2.11 | 9.34 ± 3.06 | 5.223 | 0.000 |
| Duration of delirium (days) | 2.12 ± 0.91 | 3.73 ± 1.41 | 7.394 | 0.000 |
| Composite post-reintubation complications | 0 (0.00) | 5 (8.62) | 0.026 | |
| Drug-related adverse events (total) | 15 (25.00) | 19 (32.76) | 0.866 | 0.352 |
The intervention group had a significantly shorter intervention response time (P < 0.05), lower physical restraint usage rate, shorter duration per restraint episode, and lower incidence of restraint-related skin injury (all P < 0.05). CPOT assessment completion, CAM-ICU assessment completion, timely recognition of extubation intention behaviors, pre-restraint communication documentation, and skin care implementation rates was higher in the intervention group (all P < 0.05; Table 3).
| Indicator | Intervention group (n = 60) | Control group (n = 58) | t/χ2 | P value |
| Intervention response time (seconds) | 48.22 ± 15.61 | 82.74 ± 24.32 | 9.207 | 0.000 |
| Restraint usage rate | 15 (25.00) | 26 (44.83) | 5.114 | 0.024 |
| Duration of restraint (hours) | 1.85 ± 0.61 | 3.53 ± 1.22 | 9.509 | 0.000 |
| Restraint-related skin injury | 1 (1.67) | 7 (12.07) | 0.031 | |
| CPOT assessment completion rate | 59 (98.33) | 42 (72.41) | 0.000 | |
| CAM-ICU assessment completion rate | 58 (96.67) | 40 (68.97) | 0.000 | |
| Timely recognition of extubation intention behaviors | 55 (91.67) | 36 (62.07) | 0.000 | |
| Pre-restraint communication documentation rate | 53 (88.33) | 31 (53.45) | 17.500 | 0.000 |
| Skin care implementation rate | 57 (95.00) | 45 (77.59) | 0.007 |
The intervention group had a significantly lower mean daily fluctuation in the RASS score, fewer extubation intention behaviors within 24 hours, and a lower percentage of CAM-ICU-positive days than the control group (all P < 0.05; Table 4).
| Indicator | Intervention group (n = 60) | Control group (n = 58) | t | P value |
| Mean daily fluctuation in RASS score | 0.86 ± 0.31 | 1.52 ± 0.61 | 7.446 | 0.000 |
| Frequency of extubation intention behaviors (times/24 hours) | 1.22 ± 0.57 | 3.65 ± 0.93 | 17.177 | 0.000 |
| CAM-ICU positive days (%) | 31.26 ± 7.42 | 48.64 ± 9.35 | 11.204 | 0.000 |
There were no significant differences between the groups on post-operative day 1 (P > 0.05). On post-operative day 3 and day 5, the IL-6, S100β, and NSE levels were significantly lower in the intervention group (all P < 0.05; Table 5).
| Biomarker (unit) | Timepoint | Intervention group (n = 60) | Control group (n = 58) | F (group/time/interaction) | P value |
| IL-6 (pg/mL) | Post-op day 1 | 85.40 ± 22.30 | 87.20 ± 24.10 | ||
| Post-op day 3 | 42.10 ± 12.60 | 76.50 ± 18.90 | 165.600/151.500/35.590 | 0.000 | |
| Post-op day 5 | 28.70 ± 8.40 | 65.30 ± 15.20 | |||
| S100β (ng/mL) | Post-op day 1 | 0.48 ± 0.12 | 0.49 ± 0.13 | ||
| Post-op day 3 | 0.32 ± 0.08 | 0.45 ± 0.11 | 92.500/75.460/20.020 | 0.000 | |
| Post-op day 5 | 0.24 ± 0.06 | 0.41 ± 0.09 | |||
| NSE (ng/mL) | Post-op day 1 | 18.60 ± 4.20 | 18.90 ± 4.50 | ||
| Post-op day 3 | 14.30 ± 3.10 | 17.80 ± 4.00 | 46.780/41.960/9.692 | 0.000 | |
| Post-op day 5 | 12.10 ± 2.80 | 16.50 ± 3.70 |
The mean daily fluctuation in RASS score of > 1.5, increased frequency of extubation intention behaviors (≥ 3 times/24 hours), insufficient reduction in the IL-6 level (< 30% decrease on post-operative day 3), delayed intervention response time (> 60 seconds), high restraint usage rate (> 50% of days in ICU), and low nursing assessment completion rate (< 90%) were independent risk factors for UE (all P < 0.05; Figure 1; Table 6).
| Predictor | Comparison | HR | 95%CI | P value |
| Mean daily fluctuation in RASS score | > 1.5 vs ≤ 1.5 | 3.850 | 1.421-10.447 | 0.008 |
| Frequency of extubation intention behaviors | ≥ 3 times/24 hours vs < 3 times/24 hours | 4.210 | 1.561-11.366 | 0.005 |
| Reduction in the IL-6 level on post-op day 3 | < 30% vs ≥ 30% | 2.930 | 1.101-7.818 | 0.031 |
| Intervention response time | > 60 seconds vs ≤ 60 seconds | 3.120 | 1.181-8.238 | 0.022 |
| Restraint usage rate | High (> 50% of ICU days) vs low | 2.780 | 1.051-7.358 | 0.039 |
| Nursing assessment completion rate | Low (< 90%) vs high (≥ 90%) | 3.050 | 1.142-8.147 | 0.026 |
In this retrospective study, in a clinical setting, it was confirmed that an integrated airway management strategy combined with a structured nursing pathway was effective in reducing the risk of UE in patients with POD after gastrointestinal surgery. The results demonstrated that this strategy not only significantly reduced the incidence of UE, but it also reduced the duration of mechanical ventilation, duration of stay in the ICU, and duration of delirium, while reducing post-reintubation complications. Importantly, this study systematically quantified the role of nursing measures in preventing UE. The intervention group had higher completion rates of CPOT pain assessments and CAM-ICU delirium screenings than the control group. In addition, timely recognition of extubation intention behaviors was higher in the intervention group, indicating that frequent, standardized nursing assessments are a prerequisite for early warning and timely intervention. Multivariate Cox regression analysis further confirmed that low completion of nursing assessment is an independent risk factor for UE, highlighting the critical role of standardized nursing processes in the safe management of high-risk patients.
It was also shown that the intervention group had significantly lower use of physical restraints, reduced duration per restraint episode, and reduced incidence of restraint-related skin injuries. Traditional UE prevention strategies rely heavily on deep sedation or physical restraints, both of which have significant limitations. Deep sedation may exacerbate the pathophysiology of delirium by suppressing central cholinergic pathways, disrupting the circadian rhythm, and prolonging mechanical ventilation[11,12]. Physical restraint can activate the hypothalamic-pituitary-adrenal axis, elevate the cortisol level, and promote a systemic inflammatory response, thereby aggravating hippocampal neuronal injury[13,14]. Notably, for the intervention group there was greater nursing professionalism and humanistic care in restraint decision making, and the rate of documented pre-restraint communication with patients/families was significantly higher than that of the control group. Furthermore, daily skin care and pressure-relief measures were implemented ≥ 2 times per day with a compliance rate of 95.0%, effectively reducing the restraint-related skin injury incidence to 1.67%. This approach not only aligns with the “minimal restraint” ethical principle but also reduces agitation and secondary extubation risk, demonstrating the critical value of high-quality nursing in behavior management.
A dexmedetomidine-centered α2-adrenergic receptor agonist strategy was used in this study. Dexmedetomidine stabilizes arousal by inhibiting excessive discharge of locus coeruleus noradrenergic neurons and it can directly inhibit microglial nod-like receptor protein 3 inflammasome activation, thereby reducing the release of pro-inflammatory cytokines such as IL-6[15,16]. The serum IL-6, S100β, and NSE levels on post-operative day 3 and day 5 were significantly lower in the intervention group, suggesting that the strategy may mitigate the severity of delirium by suppressing the peripheral-central inflammatory axis, reducing blood-brain barrier permeability, and alleviating neuronal injury[17,18].
Moreover, in the intervention group there were significant reductions in the frequency of extubation intention behaviors within 24 hours, mean daily fluctuation in the RASS score, and the percentage of CAM-ICU-positive days, indicating stabilization of neurobehavioral states. Reduced fluctuation in the RASS score reflects more stable depth of sedation, preventing agitation caused by inadequate sedation or paradoxical hyperactivity due to oversedation[19]. A lower percentage of CAM-ICU-positive days directly reflects a reduced delirium burden[20]. Multivariate Cox regression analysis identified increased daily fluctuation in the RASS score (> 1.5) and higher frequency of extubation intention behaviors (≥ 3 times/24 hours) as independent risk factors for UE (HR = 3.850 and HR = 4.210, respectively), consistent with previous studies[21,22]. These findings emphasize that the stability of sedation management, rather than depth alone, and control of delirium-related behaviors are key components in the prevention of UE. Frequent fluctuation in sedation awakening may disrupt cortical functional integration, aggravate disordered consciousness, and trigger self-injurious extubation behaviors[23,24].
Further analysis revealed that the intervention response time of medical nursing staff was significantly reduced in the intervention group. Optimization of this process indicator is crucial for enhancing overall safety. The improved response efficiency largely depends on the implementation of a structured nursing pathway: Hourly CPOT assessments, scheduled CAM-ICU screenings, and objective identification of extubation intention behaviors via video monitoring allow the nursing team to quickly trigger a “monitoring-warning-response” closed-loop workflow[25]. Reduced response times enable high-risk behaviors to be effectively managed before evolving into extubation events, thereby controlling risks at an early stage. This underscores the value of human factor engineering in ICU safety management: By optimizing information and decision flows, the capacity of the team to respond to complex clinical scenarios is enhanced[26].
In summary, the integrated airway management strategy significantly reduced the risk of UE in patients with POD after gastrointestinal surgery, by synergistically modulating neuroinflammation, optimizing sedation-delirium matching, reducing extubation intention behaviors, and relying on high-quality, standardized nursing monitoring and response systems. This model represents a shift from passive restraint to proactive neuroprotection, and from empirical nursing to evidence-based structured care. It not only enhances patient safety, but it also demonstrates the irreplaceable role of professional nursing in managing delirium in critically ill patients, with a strong potential for clinical scalability and generalizability.
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