Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review

Abstract

Study objective We sought to determine, using video review, the frequencies of first attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care pediatric emergency department (ED). Methods We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from pre-existing video and written records of care provided. The primary outcome was successful intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process using video review. We explored the association between physician type and first attempt success. Results We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED over 12 months. Median age was 2.4 years and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were successfully intubated on the first attempt. Seventy subjects (61%) had one or more adverse effects during RSI; 38 (33%) suffered oxyhemoglobin desaturation and two required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were noted on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Conclusions Video review of RSI revealed that first attempt failure and adverse effects were much more common than previously reported for children in an ED.

Using Video‐recorded Laryngoscopy to Evaluate Laryngoscopic Blade Approach and Adverse Events in Children

“…First-pass success rates in pediatric emergent intubation vary from 37% to 78%, and rates of adverse events are reported to be as high as 61%. [1][2][3] Video laryngoscopy has been demonstrated to improve first-pass and ultimate success and decrease iatrogenic airway trauma during endotracheal intubation in adults. [4][5][6] In addition to clinical benefit, the ability to review videos captured during laryngoscopy provides a unique opportunity to assess metrics related to procedural performance and quality of care.…”

“…1,22,23 While others have gathered information from overhead viewing, our study is the first to use recordings from video laryngoscopic attempts to assess performance metrics related to intubation. We believe this approach adds a level of precision around the timing and details related to hypopharyngeal anatomy that is not available Data are reported as n (%), unless otherwise specified.…”

“…In addition, previous work has shown that rates of complications are lower by self-report than by video review. 1 In addition, our definition of mucosal injury is more inclusive than others, in that we included any visualized blood from mucosal tissue after blade passage, whereas other definitions have used more limited definitions. 20,21 We also found increased rates of aspiration when the right-sided approach was used, although the basis for this association is less clear.…”

“…Previous work using overhead cameras and simulation has estimated intubation time. 1,[14][15][16] Our method of video recording laryngoscopy attempts offers a definitive and precise measure of this key timing interval. Neonatal resuscitation guidelines suggest intubation should occur within 30 seconds, although no similar recommendations exist for the broader pediatric population.…”

Postępowanie w niespodziewanych trudnych drogach oddechowych u dzieci — stanowisko Sekcji Anestezjologii i Intensywnej Terapii Dziecięcej, Sekcji Przyrządowego Udrażniania Dróg Oddechowych Polskiego Towarzystwa Anestezjologii i Intensywnej Terapii oraz Po

“…The incidence of major intra-operative hypoxaemic events is inversely proportional to the age of the child and is reported in about 25% of newborns, 10-15% of children under the age of 5 years and about 5% of older children [23]. Of note is fact that the actual occurrence of problems arising from difficult airways may be greater than it is reported in the official reports [24]. The risks related to difficult airways may be minimised by the use of the approriate equipment and training that includes simulation techniques [25][26][27].…”