Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department

Abstract

Objectives: Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED.Methods: We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment.Results: In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97).Conclusions: Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.

Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department

“…The primary outcome measure was peri‐intubation cardiac arrest, defined as cardiac arrest (documented chest compressions or asystole/pulseless electrical activity/ventricular fibrillation) within 10 minutes of the completion of tracheal intubation. This time frame is consistent with definitions of peri‐intubation cardiac arrest in the literature, which vary from 5 to 20 minutes 1–5,13,14,16,17,22 . 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 in‐hospital mortality.…”

“…Additionally, young age is associated with decreased first-pass success rates and peri-intubation cardiac arrest, and although age was not statistically different between groups, the median age for high-risk patients was 8.5 months. 18,22 Prospective, video-based review of the reasons for decreased firstpass success in patients with physiologically difficult airways is needed.…”

“…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.…”

“…[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).…”

“…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 1–5,13–22 . 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.…”