Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR

Ghedina, Nicole; Alkhouri, Hatem; Badge, Helen; Fogg, Toby; McCarthy, Sally

doi:10.1111/1742-6723.13416

Cited by 13 publications

(29 citation statements)

References 27 publications

(75 reference statements)

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“…The primary outcome measure was peri‐intubation cardiac arrest, defined as cardiac arrest (documented chest compressions or asystole/pulseless electrical activity/ventricular fibrillation) within 10 minutes of the completion of tracheal intubation. This time frame is consistent with definitions of peri‐intubation cardiac arrest in the literature, which vary from 5 to 20 minutes 1–5,13,14,16,17,22 . Secondary outcomes collected included first‐attempt tracheal intubation success, any postintubation cardiac arrest within the PED (regardless of time from tracheal intubation), extracorporeal membrane oxygenation (ECMO) team activation, and in‐hospital mortality.…”

Section: Methodsmentioning

confidence: 78%

“…This time frame is consistent with definitions of peri-intubation cardiac arrest in the literature, which vary from 5 to 20 minutes. [1][2][3][4][5]13,14,16,17,22 Secondary outcomes collected included first-attempt tracheal intubation success, any postintubation cardiac arrest within the PED (regardless of time from tracheal intubation), extracorporeal membrane oxygenation (ECMO) team activation, and inhospital mortality.…”

Section: Outcomes and Measuresmentioning

confidence: 99%

“…C ritically ill patients are at higher risk for serious adverse events during emergency tracheal intubation, including hypoxemia, hypotension, and cardiac arrest. [1][2][3][4][5] Efforts to improve the performance of emergency tracheal intubation have generally focused on standardizing the approach to the anatomically difficult airway. [6][7][8][9] The physiologically difficult airway has been proposed recently as a complementary concept to the anatomically difficult airway.…”

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confidence: 99%

“…[10][11][12] The reported rate of peri-intubation cardiac arrest during emergency tracheal intubation is 1.0% to 4.2% in adults and 0.8% to 3.9% in children, and peri-intubation arrest is accompanied by higher rates of in-hospital mortality. [1][2][3][4][5][13][14][15][16][17][18][19][20][21][22] Multiple attempts, hypotension, hypoxemia, and high shock index are risk factors for peri-intubation arrest in adults, 13,14,16 but the risk factors for peri-intubation cardiac arrest in children are incompletely described. Specific physiologic risk factors associated with peri-intubation cardiac arrest in children in the pediatric intensive care unit (PICU) include hemodynamic instability, hypoxemia, and cardiac disease; 4,5 however, data from other settings are limited, including the pediatric emergency department (PED).…”

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confidence: 99%

“…The reported rate of peri‐intubation cardiac arrest during emergency tracheal intubation is 1.0% to 4.2% in adults and 0.8% to 3.9% in children, and peri‐intubation arrest is accompanied by higher rates of in‐hospital mortality 1–5,13–22 . Multiple attempts, hypotension, hypoxemia, and high shock index are risk factors for peri‐intubation arrest in adults, 13,14,16 but the risk factors for peri‐intubation cardiac arrest in children are incompletely described.…”

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confidence: 99%

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Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

Dean

Hoehn

Geis

et al. 2020

Academic Emergency Medicine

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Background: The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED). Methods: This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for periintubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria. Results: Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, À18.9% difference, 95% CI = À35.5 to À1.5, p = 0.038), respectively. Conclusions: We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.

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Section: Methodsmentioning

confidence: 78%

Section: Outcomes and Measuresmentioning

confidence: 99%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

Dean

Hoehn

Geis

et al. 2020

Academic Emergency Medicine

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Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study

Hagiwara

Goto

Ohnishi

et al. 2022

Acute Medicine & Surgery

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Aim Tracheal intubation is a vital resuscitation procedure in the pediatric emergency department (ED). Despite its importance, little is known about the current status of emergency airway management in Japan. In this context, we aimed to investigate the airway management characteristics—particularly the location, patient, and provider factors—in the pediatric ED. Methods We conducted a multicenter, prospective study of five pediatric EDs in Japan from October 2018 to June 2020. The study included all children (aged ≤18 years) who underwent intubation at the pre‐ED or ED setting by physicians and those who were transferred from the ED to the operation room (OR) or pediatric intensive care unit (PICU) for intubation. We described the airway management characteristics according to the location, patient, and provider factors. Results Of 231 children, 9 (4%) were transferred to the OR or PICU for airway management. Among the remaining 222 children, 45 were intubated at the pre‐ED setting and 177 were intubated in the ED. The overall first‐attempt success rate was 72%, with the rate varying by location, patient, and provider factors—for example, 68% at the pre‐ED setting, 67% for children <2 years, 56% for children with airway‐related anatomical anomalies, and 61% with intubation by a resident physician. Intubation‐related adverse events were observed in 17%, most of which were hypoxemia (14%). Conclusions Based on data from a multicenter prospective study, the overall first‐attempt intubation success rate in pediatric EDs in Japan was 72%, with large variations by location, patient, and provider factors.

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The adjuncts for endotracheal tube passage in simulated pediatric airways (AET‐SPA) study

Gan

Shepherd

2022

JACEP Open

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Objectives To investigate whether the use of adjuncts such as stylet, railroaded bougie, and preloaded bougie increases first‐pass success rate and decreases time to successful intubation when intubating simulated infant airways using direct laryngoscopy. Methods A crossover study using experienced practitioners (who were required to carry out emergency pediatric intubations as part of their usual practice) was completed. Participants completed a random sequence of 4 intubations in simulated “easy” airways and 4 intubations in simulated “difficult” airways, using naked endotracheal tube, stylet, railroaded bougie, and preloaded bougie on standardized infant airway manikins. First‐pass success rates and times to successful intubations were measured. Results From June 1 to December 30, 2019, 109 participants performed a total of 872 intubation attempts. In the easy airway, both naked endotracheal tube (mean 96.3% [95% confidence interval 90.9%–99.0%]) and stylet (mean 98.2% [95% confidence interval 93.5%–99.8%]) had higher first‐pass success rates than railroaded bougie and preloaded bougie. In the difficult airway, stylet (mean 76.1% [95% confidence interval 67.0%–83.8%]) had the highest first‐pass success rate, followed by the naked endotracheal tube, and then both the railroaded bougie and preloaded bougie. Differences in first‐pass success rates were independent of the participants’ numbers of previous pediatric intubations. Conclusion Results of this simulation‐based study suggest that stylet should be used as the first attempt technique for infant intubations regardless of the presence or absence of predicted airway difficulty. This finding needs further validation using alternative models and in non‐simulation settings.

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Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR

Cited by 13 publications

References 27 publications

Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study

The adjuncts for endotracheal tube passage in simulated pediatric airways (AET‐SPA) study

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