Frequency and outcomes of endotracheal intubation in the pediatric emergency department

Abstract

Intubation is a core airway skill in Pediatric Emergency Medicine (PEM). The data on pediatric endotracheal intubation in the emergency department, especially in developing countries, is currently very limited. This study was designed to describe the frequency, clinical features and outcomes of pediatric intubation in a large children's hospital.We performed a retrospective analysis of PEM medical records between January 2014 and December 2015 that involved any attempted intubations of children younger than 18 years. The medical records were reviewed to describe the intubation process, demographics, clinical features and outcomes.A total of 110,000 patients visited our emergency department during the study period. Ninety-one of them (1/1300) were intubated. The median age was 2 years, (F/M: 1) and 25 patients were younger than 12 months. Respiratory failure was the most common indication for intubation (42%), followed by status epilepticus (26%) and sepsis-shock (16%). Mortality was associated with prolonged chest compression (more than 10 minute). A poor outcome was associated with sepsis-shock and cardiac diseases; however, better outcomes were associated with status epilepticus (p<0.001). The first attempt success (FAS) was achieved in 60/91 (66 %) patients and the FAS rate was also higher in younger patients (p=0.002). The discharge rate of all intubated patients in our study was sixty-four percent.Pediatric residents performed the majority of intubations. A higher FAS rate was associated with younger patients. Favorable outcomes were directly related to duration of cardiopulmonary resuscitation and main diagnosis.

Advancing emergency airway management practice and research

“…Indeed, the first‐pass success rate in children aged <18 years was 60% (and 50% in children aged <2 years) in Japanese EDs, whereas the rate was 74% in overall ED patients . In other studies, the first‐pass success rates in children varied from 39% to 78% . Furthermore, published works have shown that the intubator's experience plays a major role in first‐pass success in children.…”

“…As intubation for children is a rare event (e.g., 2–33/10,000 ED visits), emergency physicians are likely unfamiliar with airway management in children. Additionally, the highly stressed clinical situation within limited resources might further contribute to low success rates and errors, such as miscalculation for medication doses .…”

“…In children, the lower functional residual volume and higher oxygen metabolism cause hypoxia more quickly than adults . Although it has been reported that RSI improves the success rate in children similar to adults, intubation without RSI (e.g., awake intubation with preserved spontaneous respiration) is undertaken more frequently compared to adults . Additionally, apneic oxygenation was associated with a lower risk of hypoxemia during intubation of children in the ED …”

Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments

“…Respiratory compromise is a significant cause of morbidity and mortality in pediatric patients and although tracheal intubation can be a life-saving intervention, it is not without risks and complications. [1][2][3][4] Adverse tracheal intubation-associated events in the EDs have been reported at a rate of 19%-39%, with esophageal intubation, endobronchial intubation, desaturation, and hypotension being more common. [1][2][3]5 Tracheal intubation is also an uncommon event at the Emergency Departments (EDs) with an occurrence of 8-10 per 10 000 patient visits and consequentially, physicians may be less familiar with the procedure as evidenced by a variable first-pass intubation rate ranging from 60% to 83%.…”

“…[1][2][3]5 Tracheal intubation is also an uncommon event at the Emergency Departments (EDs) with an occurrence of 8-10 per 10 000 patient visits and consequentially, physicians may be less familiar with the procedure as evidenced by a variable first-pass intubation rate ranging from 60% to 83%. [1][2][3][4][5][6] General and pediatric EDs may vary in their preparedness to manage children with airway emergencies due to disparities in clinical expertise, prior training, and availability of appropriately sized equipment. [7][8][9] Little is known about how intubation outcomes compare between general and pediatric EDs.…”