Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs

Li, Simon; Hsieh, Ting-Chang; Rehder, Kyle J; Nett, Sholeen; Kamat, Pradip; Napolitano, Natalie; Turner, David A.; Adu‐Darko, Michelle; Jarvis, Janet; Krawiec, Conrad; Derbyshire, Ashley T.; Meyer, Keith; Giuliano, John S.; Tala, Joana; Tarquinio, Keiko M.; Ruppe, Michael; Sanders, Ronald C.; Pinto, Matthew; Howell, Joy; Parker, Margaret M.; Nuthall, Gabrielle; Shepherd, Michael; Émériaud, Guillaume; Nagai, Yuki; Saito, Osamu; Lee, Jan Hau; Simon, Dennis; Orioles, Alberto; Walson, Karen; Vanderford, Paula A.; Shenoi, Asha; Lee, Anthony; Bird, Geoffrey L.; Miksa, Michael; Graciano, Ana Lía; Bain, Jesse; Skippen, Peter; Polikoff, Lee; Nadkarni, Vinay; Nishisaki, Akira

doi:10.1097/pcc.0000000000001384

Cited by 52 publications

(43 citation statements)

References 30 publications

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“…The primary outcome was the first-attempt intubation success rate. The secondary outcomes were the presence of desaturation defined as an oxygen saturation <80% during tracheal intubation in children with an initial oxygen saturation >90% after preoxygenation [ 17 ] and presence of tracheal intubation associated events. Based on several intubation studies, severe tracheal intubation–associated events included cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum, and direct airway injury.…”

Section: Methodsmentioning

confidence: 99%

Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department

Couto¹,

Reis²,

Farhat³

et al. 2020

Medicine

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The aim of this study was to compare the success of first-attempt tracheal intubation in pediatric patients >1-year old performed using video versus direct laryngoscopy and compare the frequency of tracheal intubation–associated events and desaturation among these patients. Prospective observational cohort study conducted in an Academic pediatric tertiary emergency department. We compared 50 children intubated with Mcgrath Mac video laryngoscope (VL group) and an historical series of 141 children intubated with direct laryngoscopy (DL group). All patients were aged 1 to 18 years. The first attempt success rates were 68% (34/50) and 37.6% (53/141) in the VL and DL groups ( P < .01), respectively. There was a lower proportion of tracheal intubation–associated events in the VL group (VL, 31.3% [15/50] vs DL, 67.8% [97/141]; P < .01) and no significant differences in desaturation (VL, 35% [14/50] vs DL 51.8% [72/141]; P = .06). The median number of attempts was 1 (range, 1–5) for the VL group and 2 (range, 1–8) for the DL group ( P < .01). Multivariate logistic regression showed that video laryngoscope use was associated with higher chances of first-attempt intubation with an odds ratio of 4.5 (95% confidence interval, 1.9–10.4, P < 0.01). Compared with direct laryngoscopy, VL was associated with higher success rates of first-attempt tracheal intubations and lower rates of tracheal intubation–associated events.

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Section: Methodsmentioning

confidence: 99%

Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department

Couto¹,

Reis²,

Farhat³

et al. 2020

Medicine

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“…While the definition of adverse TIAEs does not include hypoxemia, these are often reported together. Current evidence suggests 1. adverse TIAEs and hypoxemia are common in airway management in the pediatric ICUs, Emergency Department, and neonatal ICUs, 2. patient, clinician, and practice factors are associated with the occurrence of these adverse events, and 3. interdisciplinary quality improvement has helped reduce these events . Pediatric anesthesiologists can partner with nonanesthesiologists to improve the safety of airway management in these clinical locations.…”

Section: Airway Management In the Pediatric Icu Emergency Departmentmentioning

confidence: 99%

“…Conversely, the TIs with hypoxemia SpO2 < 80% experienced hemodynamic TIAEs (ie, cardiac arrest, hypo/hypertension, dysrhythmia) more often (9.8% vs. 4.4% of TIs without oxygen desaturation). After adjusting for patient conditions and clinician levels, the odds ratio (OR) for these hemodynamic TIAEs was 1.83 (95% CI 1.34‐2.51) in tracheal intubations with hypoxemia (SpO2 < 80%) and 2.16 (95% CI 1.54‐3.04) in tracheal intubations with severe hypoxemia (SpO2 < 70%) . The occurrence of adverse TIAEs or oxygen desaturation was independently associated with a longer duration of mechanical ventilation in the ICU (+12%, 95% CI 4%‐21%), and the occurrence of severe TIAEs was independently associated with increased pediatric ICU mortality (OR 1.80, 95% CI 1.24‐2.60) .…”

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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“…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% …”

Section: Is There a Problem?mentioning

confidence: 99%

Emergency intubation of children outside of the operating room

Long

Barrett

Peters

et al. 2020

Pediatric Anesthesia

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Intubation of children outside of the operating room is performed infrequently and is often associated with life‐threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non‐operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems‐based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi‐disciplinary team training in the technical and nontechnical aspects of non‐operating room intubation, debrief post–real and simulated events, and regular audit of performance all reduce life‐threatening intubation‐related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient‐centered care delivery.

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Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs

Cited by 52 publications

References 30 publications

Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department

Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department

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

Emergency intubation of children outside of the operating room

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