Endotracheal intubation by a specialised paediatric retrieval team

Abstract

Objectives Intubation of critically ill children is an infrequent procedure, and is associated with significant risk. We set out to describe intubations carried out by the Children's Health Queensland Retrieval Service (CHQRS), with the intention to identify areas for improvement in the performance of intubation in the retrieval setting. Methods Paediatric patients undergoing transport while intubated were identified, and cases where intubation occurred after the arrival of the CHQRS team were examined. Results Over the study period of January 2015 to September 2018, 498 intubated retrievals were undertaken; 85 patients were intubated after the arrival of CHQRS; the age range was 1 day to 16.5 years (median 0.5, interquartile range [IQR] 0.11–3 years). The median weight was 6.2 kg (IQR 3.7–16.5 kg). The pathology requiring intubation included respiratory 36 (42.3%), sepsis 21 (24.7%), neurological 11 (12.9%) and trauma 7 (8.2%). A total of 470 of 498 (94.4%) of intubated patients were from regional referral or tertiary hospitals, 28 of 498 (5.6%) were from rural and remote facilities. Of 85 patients, 57 (67.1%) were intubated by CHQRS and 28 (32.9%) were intubated by a doctor from the referring facility. The CHQRS team was more likely to perform the intubation in smaller children (median weight 5.0 vs 9.9 kg, P = 0.03). The mean scene time was 2.8 h. The scene time was shorter if the intubation was performed by CHQRS (mean 2.6 h, median 2.5, IQR 1.8–3.3; median 3, IQR 2.2–3.9; P = 0.048). The scene time was shorter when the intubation was predicted from tasking information (2.6 vs 3.1 h; P = 0.03). Conclusion Paediatric endotracheal intubation is an infrequent procedure in our service. An airway registry could improve documentation and gather information to identify specific training requirements and areas for practice improvement.

Emergency intubation of children outside of the operating room

“…One in four major adverse events occurred in the emergency department (ED) or intensive care unit (ICU), and these adverse events were more likely to result in permanent disability or death compared to major adverse events in the OR. A high adverse event rate has been replicated in every non‐OR setting in which performance has been audited . Systems‐based changes have been proposed to reduce avoidable deaths due to airway complications in the prehospital setting, in the ED, and in the ICU, such as standardization of approach and equipment, clear pathways for airway escalation, use of checklists, use of endtidal capnography to confirm correct endotracheal tube placement, joint training in airway technical and nontechnical skills, and debriefing post–real and simulated events .…”

“…In particular, peri‐intubation hypoxemia and hypotension are major predictors of life‐threatening adverse events and death . In pediatric prehospital, ED, and ICU settings, the reported rates of peri‐intubation hypoxemia range from 2% to 47%, of hypotension range from 1% to 21%, and of cardiac arrest range from 0% to 10% …”

“…Intubation outside of the OR occurs uncommonly. Fewer than 20/1000 prehospital retrievals, fewer than 1/1000 of ED patient visits, and fewer than 65/1000 of ICU admissions require intubation . For large academic departments, this equates to roughly one intubation every 5 days in the ED, and one intubation every 2.5 days in ICU.…”

Rural and Remote Intubations in An Australian Aeromedical Retrieval Service: A Retrospective Cohort Study.

“…This study does not consider the specialised paediatric and neonate retrieval services that exist in the state and the missions they perform on this subset of patient groups, while noting recent publication in this area. (2) Future Work…”

“…(1) As well as the 'general' retrieval teams which move patients of any age, Queensland also has dedicated specialised paediatric and neonatal retrieval services. (2) Queensland is a large state covering 1.853 million km 2 , with the majority of the population concentrated down the east coast, particularly in the south east corner including the major cities of Brisbane and Gold Coast. (3) As a result, larger specialist hospitals are predominantly located in these areas (Appendix 1:…”