Current Medication Practice and Tracheal Intubation Safety Outcomes From a Prospective Multicenter Observational Cohort Study*

Tarquinio, Keiko M.; Howell, Joy; Montgomery, Vicki; Turner, David A.; Hsing, Deyin D.; Parker, Margaret M.; Brown, Calvin A.; Walls, Ron M.; Nadkarni, Vinay; Nishisaki, Akira

doi:10.1097/pcc.0000000000000319

Cited by 51 publications

(38 citation statements)

References 38 publications

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“…(9–16) In the pediatric ICU setting, severe adverse events occurred in approximately 6% of cases and less than 2% of patients progressed to cardiac arrest during the event. (11, 14) Similar, or slightly higher, cardiac arrest event rates have been described in the ED for pediatric(18) and adult(30, 31) patients in relation to emergency intubation. These estimates are lower than the 9.3% reported here.…”

Section: Discussionsupporting

confidence: 55%

Pediatric In-Hospital Acute Respiratory Compromise: A Report From the American Heart Association’s Get With the Guidelines-Resuscitation Registry*

Andersen¹,

Vognsen

Topjian

et al. 2017

Pediatric Critical Care Medicine

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Objectives The main objectives of this study were to describe in-hospital acute respiratory compromise among children (age < 18 years), and its association with cardiac arrest and in-hospital mortality. Design Observational study using prospectively collected data. Setting United States hospitals reporting data to the Get With The Guidelines® – Resuscitation registry. Patients Pediatric patients (age < 18 years) with acute respiratory compromise. Acute respiratory compromise was defined as absent, agonal, or inadequate respiration that required emergency assisted ventilation and elicited a hospital-wide or unit-based emergency response. Interventions None. Measurements and Main Results The primary outcome was in-hospital mortality. Cardiac arrest during the event was a secondary outcome. To assess the association between patient, event, and hospital characteristics and the outcomes, we created multivariable logistic regressions models accounting for within-hospital clustering. One thousand nine hundred and fifty two patients from 151 hospitals were included. Forty percent of the events occurred on the wards, 19% in the emergency department, 25% in the intensive care unit, and 16% in other locations. Two hundred eighty patients (14.6%) died before hospital discharge. Pre-existing hypotension (odds ratio: 3.26 [95%CI: 1.89, 5.62], p < 0.001) and septicemia (odds ratio: 2.46 [95%CI: 1.52, 3.97], p < 0.001) were associated with increased mortality. The acute respiratory compromise event was temporally associated with a cardiac arrest in 182 patients (9.3%), among whom 46.2% died. One thousand two hundred and eight patients (62%) required tracheal intubation during the event. In-hospital mortality among patients requiring tracheal intubation during the event was 18.6%. Conclusion In this large, multicenter study of acute respiratory compromise, 40% occurred in ward settings, 9.3% had an associated cardiac arrest, and overall in-hospital mortality was 14.6%. Pre-event hypotension and septicemia were associated with increased mortality rate.

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Section: Discussionsupporting

confidence: 55%

Pediatric In-Hospital Acute Respiratory Compromise: A Report From the American Heart Association’s Get With the Guidelines-Resuscitation Registry*

Andersen¹,

Vognsen

Topjian

et al. 2017

Pediatric Critical Care Medicine

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“…In the pediatric ICUs and EDs, intravenous induction with neuromuscular blockade agent is a standard of care, unless there is strong concern for difficult mask ventilation after neuromuscular blockade administration as discussed above . A standard induction (administration of sedative/induction agent) with mask ventilation followed by neuromuscular blocker administration is practiced commonly in the airway management in the ICUs .…”

Section: Airway Management In the Pediatric Icu Emergency Departmentmentioning

confidence: 99%

Normal and difficult airways in children: “What’s New”—Current evidence

Fiadjoe

Nishisaki

2020

Pediatric Anesthesia

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Background Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit. Methods Expert review of the recent literature. Results Cognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the pediatric intensive care unit, emergency department and neonatal intensive care units, adverse tracheal intubation–associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the operating room. Similarly, a multicenter neonatal intensive care unit study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration. Conclusion Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with intensive care and emergency department and neonatology clinicians to improve the safety of airway management in all clinical settings.

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“…[64,65] Ketamine, another safe and valuable agent for endotracheal intubation, does not increase the risk of side-effect in septic patients. [66,67] Although animal studies showed that propofol could significantly inhibit myocardial and circulatory function, [68] Tang et al [69][70][71] found that propofol has a beneficial effect on the regulation of inflammatory response. Thus we must be careful when propofol is used in septic patients.…”

Section: Midazolam Propofol Ketamine and Etomidatementioning

confidence: 99%

Expert consensus on the perioperative management of patients with sepsis

Anesthesiologists¹

2015

World Journal of Emergency Medicine

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Current Medication Practice and Tracheal Intubation Safety Outcomes From a Prospective Multicenter Observational Cohort Study*

Abstract: In this large, pediatric multicenter registry, fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.

Cited by 51 publications

References 38 publications

Pediatric In-Hospital Acute Respiratory Compromise: A Report From the American Heart Association’s Get With the Guidelines-Resuscitation Registry*

Pediatric In-Hospital Acute Respiratory Compromise: A Report From the American Heart Association’s Get With the Guidelines-Resuscitation Registry*

Normal and difficult airways in children: “What’s New”—Current evidence

Expert consensus on the perioperative management of patients with sepsis

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