Risk Factors for Peri-Intubation Cardiac Arrest in Pediatric Cardiac Intensive Care Patients: A Multicenter Study*

Abstract

Objectives: Endotracheal intubation is associated with hemodynamic adverse events, including cardiac arrest, especially in patients with cardiac disease. There are only a few studies that have evaluated the rate of and risk factors for endotracheal intubation hemodynamic complications in critically ill pediatric patients. Although some of these studies have assessed hemodynamic complications during intubation in pediatric cardiac patients, the frequency of and risk factors for peri-intubation cardiac arrest have not been adequately described in high acuity cardiac patients. This study aims to describe the frequency of and risk factors for peri-intubation cardiac arrest in critically ill pediatric cardiac patients admitted to specialized cardiac ICUs. Design: Multicenter retrospective cohort study. Setting: Three pediatric cardiac ICUs in the United States. Patients: Critically ill pediatric patients with congenital or acquired heart disease requiring endotracheal intubation. Interventions: None. Measurements and Main Results: Endotracheal intubations performed in three cardiac ICUs between January 2015 and December 2017 were reviewed. Clinical variables—including data on patients, clinical providers, and procedure—were evaluated for their association with peri-intubation cardiac arrest. There was a total of 186 intubation events studied, occurring in 151 individual (index) patients. The rates of peri-intubation cardiac arrest and peri-intubation mortality in this cohort were 7% and 1.6%, respectively. Among those patients with moderate or severe systolic dysfunction of the systemic ventricle, peri-intubation cardiac arrest rate was 20.7%. Statistically significant risk factors for peri-intubation cardiac arrest included: significant systolic dysfunction of the systemic ventricle, pre-intubation hypotension, pre-intubation lactate elevation, lower pre-intubation pH, and documented oxygen desaturations (> 10%) during intubation procedure. Conclusions: Our most significant finding was a peri-intubation cardiac arrest rate which was much higher than previously published rates for both cardiac and noncardiac children who underwent endotracheal intubation in ICUs. Peri-intubation mortality was also high in our cohort. Regarding risk factors for peri-intubation arrest, significant systolic dysfunction of the systemic ventricle was strongly associated with cardiac arrest in this cohort.

Heart Disease and Stroke Statistics—2023 Update: A Report From the American Heart Association

“…A retrospective analysis of 3 US pediatric ICUs from 2015 to 2017 found a 7% incidence of cardiac arrest in patients undergoing endotracheal intubation. 54…”

First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways

“…5,8 Hypoxemia and hypotension are particularly hazardous risks for cardiac arrest. [9][10][11][12][13] Unfortunately, data are lacking regarding the effect of physiologically difficult airways on FPS-AE in the emergency department (ED). This study explores the association of physiologically and anatomically difficult airways with FPS-AE.…”

Peri-Intubation Cardiorespiratory Arrest Risk in Pediatric Patients: A Systematic Review

“…A total of 11 studies with 14,424 intubations were included in the final analyses. 2 7 8 9 11 12 13 14 15 16 17 The search strategy for these studies is outlined in Fig. 1 .…”

“…Previous studies have identified hypotension, hypoxemia, lower pH, and systemic ventricular dysfunction, recent cardiorespiratory arrest, status asthmaticus, and the need for multiple intubation attempts to be associated with increased risk of peri-intubation risk of cardiorespiratory arrest. 7,8,12,14,15 Previous studies have identified the use of ketamine to be associated with decreased risk of peri-intubation cardiorespiratory arrest. 11 The transition from negative pressure to positive pressure ventilation is associated with a significant change in physiology.…”

“…7 While another study performed by Esangbedo et al showed that impaired systolic function, hypotension, lactic acidosis, and low oxygen saturation were associated with cardiac arrest in 186 patients from three cardiac intensive care units. 8 The importance of this issue, particularly in high-acuity settings like the emergency department, has led some to develop strategies to minimize the risk of peri-intubation cardiac arrest by forming a team formed by both emergency department and PICU personnel. 9 The primary objective of this study was to determine the risk of peri-intubation cardiorespiratory arrest in pediatric patients intubated in a hospital setting by pooling published data.…”