Safety of tracheal intubation in the presence of cardiac disease in paediatric ICUs

Gradidge, Eleanor; Bakar, Adnan; Téllez, David; Ruppe, Michael; Tallent, Sarah; Bird, Geoffrey L.; Lavin, Natasha; Lee, Anthony; Adu‐Darko, Michelle; Bain, Jesse; Biagas, Katherine; Branca, Aline; Breuer, Ryan; Brown, Calvin A.; Bysani, Kris; Émériaud, Guillaume; Gangadharan, Sandeep; Giuliano, John S.; Howell, Joy; Krawiec, Conrad; Lee, Jan Hau; Li, Simon; Meyer, Keith; Miksa, Michael; Napolitano, Natalie; Nett, Sholeen; Nuthall, Gabrielle; Orioles, Alberto; Owen, Erin B.; Parker, Margaret M.; Parsons, Simon; Polikoff, Lee; Rehder, Kyle J; Saito, Osamu; Sanders, Ron C.; Shenoi, Asha; Simon, Dennis; Skippen, Peter; Tarquinio, Keiko M.; Thompson, Anne; Toedt‐Pingel, Iris; Walson, Karen; Nishisaki, Akira; Investigators, Sepsis

doi:10.1017/s1047951118000495

Cited by 16 publications

(16 citation statements)

References 25 publications

(41 reference statements)

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“…To address this driver, the improvement team developed high-risk criteria that would trigger PET activation. The improvement team drafted an initial list of criteria based on existing literature; 1 , 4 , 5 reviews of the ten most recent cardiac arrest cases within 4 hours of PICU admission, and more than 10 years of video-based case reviews of tracheal intubations in the PED. The improvement team then revised the criteria by applying them to a historical cohort of 20 STS patients who had undergone tracheal intubation in the PED and group discussion, which continued until consensus was achieved.…”

Section: Methodsmentioning

confidence: 99%

“…Cardiac disease, hypoxemia, and hypotension have previously been identified as risk factors for peri-intubation cardiac arrest. 1 , 4 , 5 Identifying these risk factors is necessary but insufficient to mitigate the risk of peri-intubation cardiac arrest. Since physiologically high-risk pediatric intubations are low-frequency events, 6 a system-level improvement process is needed to decrease the risk of mortality.…”

Section: Introductionmentioning

confidence: 99%

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Peri-Intubation Cardiac Arrest in the Pediatric Emergency Department: A Novel System of Care

Hoehn

Dean

Lautz

et al. 2020

Pediatric Quality &Amp; Safety

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Introduction: Patients with physiologic disorders, such as hypoxemia or hypotension, are at high risk of peri-intubation cardiac arrest. Standardization improves emergency tracheal intubation safety, but no published reports describe initiatives to reduce the risk of cardiac arrest. This initiative aims to improve the care of children at risk of peri-intubation cardiac arrest in a pediatric emergency department (PED). We specifically aimed to increase the number of patients between those with peri-intubation cardiac arrest by 50%, from a baseline of 11–16, over 12-months. Methods: Our multidisciplinary team outlined a theory of improvement and designed interventions aimed at key drivers. The primary intervention was creating a PICU-ED Team (PET) and a checklist to guide the assessment and mitigation of risk for peri-intubation arrest and rapid consultation of the pediatric intensivists. The PET was iteratively refined, and we collected data by a video review of tracheal intubations. Results: Fifty-one patients with risk factors for peri-intubation arrest underwent tracheal -intubation in the PED from January 2016 to March 2020: 14 with PET activation since PET go-live in April 2019. None of the 14 PET patients had a peri-intubation cardiac arrest. Ninety-three percent (13/14) of PET patients were intubated in the PED, and 78% (10/13) of these patients had the first intubation attempt completed by PED physicians (balancing measures). Conclusion: We successfully developed the PET to mitigate the risk of peri-intubation cardiac arrest without significantly reducing key procedural opportunities for the PED. Initial data are promising, but further refinement is needed.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Peri-Intubation Cardiac Arrest in the Pediatric Emergency Department: A Novel System of Care

Hoehn

Dean

Lautz

et al. 2020

Pediatric Quality &Amp; Safety

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“…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.…”

mentioning

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).…”

mentioning

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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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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Safety of tracheal intubation in the presence of cardiac disease in paediatric ICUs

Cited by 16 publications

References 25 publications

Peri-Intubation Cardiac Arrest in the Pediatric Emergency Department: A Novel System of Care

Peri-Intubation Cardiac Arrest in the Pediatric Emergency Department: A Novel System of Care

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

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