76
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Sawyer T, Foglia EE, Ades A, Moussa A, Napolitano N, Glass K, Johnston L, Jung P, Singh N, Quek BH, Barry J, Zenge J, DeMeo SD, Brei B, Krick J, Kim JH, Nadkarni V, Nishisaki A. Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed 2019; 104:F461-F466. [PMID: 30796059 DOI: 10.1136/archdischild-2018-316336] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/07/2019] [Accepted: 02/06/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU). DESIGN Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates. SETTING Ten academic NICUs. PATIENTS Neonates intubated in the NICU at each of the sites between October 2014 and March 2017. MAIN OUTCOME MEASURES Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation. RESULTS Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53). CONCLUSIONS Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.
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MESH Headings
- Airway Management/methods
- Clinical Competence
- Emergencies/epidemiology
- Female
- Humans
- Hypoxia/etiology
- Hypoxia/prevention & control
- Incidence
- Infant, Newborn
- Infant, Premature
- Intensive Care Units, Neonatal/standards
- Intensive Care Units, Neonatal/statistics & numerical data
- Intubation, Intratracheal/adverse effects
- Intubation, Intratracheal/methods
- Intubation, Intratracheal/standards
- Intubation, Intratracheal/statistics & numerical data
- Male
- Outcome Assessment, Health Care
- Practice Patterns, Physicians'/standards
- Quality Improvement/standards
- Registries
- Retrospective Studies
- United States/epidemiology
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77
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Mayordomo-Colunga J, González-Cortés R, Bravo MC, Martínez-Mas R, Vázquez-Martínez JL, Renter-Valdovinos L, Conlon TW, Nishisaki A, Cabañas F, Bilbao-Sustacha JÁ, Oulego-Erroz I. [Point-of-care ultrasound: Is it time to include it in the paediatric specialist training program?]. An Pediatr (Barc) 2019; 91:206.e1-206.e13. [PMID: 31395389 DOI: 10.1016/j.anpedi.2019.06.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/22/2019] [Indexed: 11/16/2022] Open
Abstract
Point-of-care ultrasound (POCUS) has become an essential tool for clinical practice in recent years. It should be considered as an extension of the standard physical examination, which complements and enriches it without substituting it. POCUS enables the physician to answer specific clinical questions about the diagnosis, to understand better the pathophysiological context, to orientate the treatment, and to perform invasive procedures more safely. Despite its current use in many centres, and in most paediatric sub-specialties, there are currently no specific recommendations addressing educational aims in the different training areas, as well as methodology practice and the certification process in paediatrics. These ingredients are essential for POCUS implementation in daily practice, with a quality guarantee in terms of efficiency and safety. Several POCUS experts in different paediatric medicine environments performed a non-systematic review addressing the main paediatric POCUS applications in paediatrics. The lack of educational programs in POCUS in Spain is also discussed, and the experience in the United States of America in this topic is provided. Considering the current situation of POCUS in paediatrics, we strongly believe that it is urgent to establish evidence-based recommendations for POCUS training that should be the base to develop educational programs and to include POCUS in the paediatric residency training.
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78
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Conlon TW, Lin EE, Bruins BB, Manrique Espinel AM, Muhly WT, Elliott E, Glau C, Himebauch AS, Johnson G, Fiadjoe JE, Lockman JL, Nishisaki A, Schwartz AJ. Getting to know a familiar face: Current and emerging focused ultrasound applications for the perioperative setting. Paediatr Anaesth 2019; 29:672-681. [PMID: 30839154 DOI: 10.1111/pan.13625] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 02/26/2019] [Accepted: 03/03/2019] [Indexed: 12/18/2022]
Abstract
Ultrasound technology is available in many pediatric perioperative settings. There is an increasing number of ultrasound applications for anesthesiologists which may enhance clinical performance, procedural safety, and patient outcomes. This review highlights the literature and experience supporting focused ultrasound applications in the pediatric perioperative setting across varied disciplines including anesthesiology. The review also suggests strategies for building educational and infrastructural systems to translate this technology into clinical practice.
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79
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Conlon TW, Kantor DB, Su ER, Nishisaki A. The authors reply. Pediatr Crit Care Med 2019; 20:592-593. [PMID: 31162366 PMCID: PMC6730658 DOI: 10.1097/pcc.0000000000001950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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80
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Sanders R, Edwards L, Nishisaki A. Tracheal Intubations for Critically Ill Children Outside Specialized Centers in the United Kingdom-Patient, Provider, Practice Factors, and Adverse Events. Pediatr Crit Care Med 2019; 20:572-573. [PMID: 31162351 PMCID: PMC6550333 DOI: 10.1097/pcc.0000000000001946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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81
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Kirschen MP, Francoeur C, Murphy M, Traynor D, Zhang B, Mensinger JL, Ichord R, Topjian A, Berg RA, Nishisaki A, Morrison W. Epidemiology of Brain Death in Pediatric Intensive Care Units in the United States. JAMA Pediatr 2019; 173:469-476. [PMID: 30882855 PMCID: PMC6503509 DOI: 10.1001/jamapediatrics.2019.0249] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Guidelines for declaration of brain death in children were revised in 2011 by the Society of Critical Care Medicine, American Academy of Pediatrics, and Child Neurology Society. Despite widespread medical, legal, and ethical acceptance, ongoing controversies exist with regard to the concept of brain death and the procedures for its determination. OBJECTIVES To determine the epidemiology and clinical characteristics of pediatric patients declared brain dead in the United States. DESIGN, SETTING, AND PARTICIPANTS This study involved the abstraction of all patient deaths from the Virtual Pediatric Systems national multicenter database between January 1, 2012, and June 30, 2017. All patients who died in pediatric intensive care units (PICUs) were included. MAIN OUTCOMES AND MEASURES Patient demographics, preillness developmental status, severity of illness, cause of death, PICU medical and physical length of stay, and organ donation status, as well as comparison between patients who were declared brain dead vs those who sustained cardiovascular or cardiopulmonary death. RESULTS Of the 15 344 patients who died, 3170 (20.7%) were declared brain dead; 1861 of these patients (58.7%) were male, and 1401 (44.2%) were between 2 and 12 years of age. There was a linear association between PICU size and number of patients declared brain dead per year, with an increase of 4.27 patients (95% CI, 3.46-5.08) per 1000-patient increase in discharges (P < .001). The median (interquartile range) of patients declared brain dead per year ranged from 1 (0-3) in smaller PICUs (defined as those with <500 discharges per year) to 10 (7-15) for larger PICUs (those with 2000-4000 discharges per year). The most common causative mechanisms of brain death were hypoxic-ischemic injury owing to cardiac arrest (1672 of 3170 [52.7%]), shock and/or respiratory arrest without cardiac arrest (399 of 3170 [12.6%]), and traumatic brain injury (634 of 3170 [20.0%]). Most patients declared brain dead (681 of 807 [84.4%]) did not have preexisting neurological dysfunction. Patients who were organ donors (1568 of 3144 [49.9%]) remained in the PICU longer after declaration of brain death compared with those who were not donors (median [interquartile range], 29 [6-41] hours vs 4 [1-8] hours; P < .001). CONCLUSIONS AND RELEVANCE Brain death occurred in one-fifth of PICU deaths. Most children declared brain dead had no preexisting neurological dysfunction and had an acute hypoxic-ischemic or traumatic brain injury. Brain death determinations are infrequent, even in large PICUs, emphasizing the importance of ongoing education for medical professionals and standardization of protocols to ensure diagnostic accuracy and consistency.
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82
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Lindell RB, Nishisaki A, Weiss SL, Balamuth F, Traynor DM, Chilutti MR, Grundmeier RW, Fitzgerald JC. Comparison of Methods for Identification of Pediatric Severe Sepsis and Septic Shock in the Virtual Pediatric Systems Database. Crit Care Med 2019; 47:e129-e135. [PMID: 30394917 PMCID: PMC6336511 DOI: 10.1097/ccm.0000000000003541] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To compare the performance of three methods of identifying children with severe sepsis and septic shock from the Virtual Pediatric Systems database to prospective screening using consensus criteria. DESIGN Observational cohort study. SETTING Single-center PICU. PATIENTS Children admitted to the PICU in the period between March 1, 2012, and March 31, 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, all PICU patients were prospectively screened daily for sepsis, and those meeting consensus criteria for severe sepsis or septic shock on manual chart review were entered into the sepsis registry. Of 7,459 patients admitted to the PICU during the study period, 401 met consensus criteria for severe sepsis or septic shock (reference standard cohort). Within Virtual Pediatric Systems, patients identified using "Martin" (n = 970; κ = 0.43; positive predictive value = 34%; F1 = 0.48) and "Angus" International Classification of Diseases, 9th Edition, Clinical Modification codes (n = 1387; κ = 0.28; positive predictive value = 22%; F1 = 0.34) showed limited agreement with the reference standard cohort. By comparison, explicit International Classification of Diseases, 9th Edition, Clinical Modification codes for severe sepsis (995.92) and septic shock (785.52) identified a smaller, more accurate cohort of children (n = 515; κ = 0.61; positive predictive value = 57%; F1 = 0.64). PICU mortality was 8% in the reference standard cohort and the cohort identified by explicit codes; age, illness severity scores, and resource utilization did not differ between groups. Analysis of discrepancies between the reference standard and Virtual Pediatric Systems explicit codes revealed that prospective screening missed 66 patients with severe sepsis or septic shock. After including these patients in the reference standard cohort as an exploratory analysis, agreement between the cohort of patients identified by Virtual Pediatric Systems explicit codes and the reference standard cohort improved (κ = 0.73; positive predictive value = 70%; F1 = 0.75). CONCLUSIONS Children with severe sepsis and septic shock are best identified in the Virtual Pediatric Systems database using explicit diagnosis codes for severe sepsis and septic shock. The accuracy of these codes and level of clinical detail available in the Virtual Pediatric Systems database allow for sophisticated epidemiologic studies of pediatric severe sepsis and septic shock in this large, multicenter database.
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83
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Walker S, Conlon T, Zhang B, Mensinger J, Fitzgerald J, Himebauch A, Glau C, Nishisaki A, Ranjit S, Nadkarni V, Weiss S. 1674. Crit Care Med 2019. [DOI: 10.1097/01.ccm.0000552413.40173.c7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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84
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Foglia EE, Ades A, Sawyer T, Glass KM, Singh N, Jung P, Quek BH, Johnston LC, Barry J, Zenge J, Moussa A, Kim JH, DeMeo SD, Napolitano N, Nadkarni V, Nishisaki A. Neonatal Intubation Practice and Outcomes: An International Registry Study. Pediatrics 2019; 143:peds.2018-0902. [PMID: 30538147 PMCID: PMC6317557 DOI: 10.1542/peds.2018-0902] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety. METHODS We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression. RESULTS We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57). CONCLUSIONS We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.
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85
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Pouppirt NR, Nassar R, Napolitano N, Nawab U, Nishisaki A, Nadkarni V, Ades A, Foglia EE. Association Between Video Laryngoscopy and Adverse Tracheal Intubation-Associated Events in the Neonatal Intensive Care Unit. J Pediatr 2018; 201:281-284.e1. [PMID: 29980290 PMCID: PMC6288797 DOI: 10.1016/j.jpeds.2018.05.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/23/2018] [Accepted: 05/30/2018] [Indexed: 11/19/2022]
Abstract
The effect of video laryngoscopy on adverse events during neonatal tracheal intubation is unknown. In this single site retrospective cohort study, video laryngoscopy was independently associated with decreased risk for adverse events during neonatal intubation.
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86
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Glau CL, Nishisaki A. The authors reply. Pediatr Crit Care Med 2018; 19:914. [PMID: 30180137 DOI: 10.1097/pcc.0000000000001665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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87
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Sawyer T, Foglia E, Hatch LD, Moussa A, Ades A, Johnston L, Nishisaki A. Improving neonatal intubation safety: A journey of a thousand miles. J Neonatal Perinatal Med 2018; 10:125-131. [PMID: 28409758 DOI: 10.3233/npm-171686] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Neonatal intubation is one of the most common procedures performed by neonatologists, however, the procedure is difficult and high risk. Neonates who endure the procedure often experience adverse events, including bradycardia and severe oxygen desaturations. Because of low first attempt success rates, neonates are often subjected to multiple intubation attempts before the endotracheal tube is successfully placed. These factors conspire to make intubation one of the most dangerous procedures in neonatal medicine. In this commentary we review key elements in the journey to improve neonatal intubation safety. We begin with a review of intubation success rates and complications. Then, we discuss the importance of intubation training. Next, we examine quality improvement efforts and patient safety research to improve neonatal intubation safety. Finally, we evaluate new tools which may improve success rates, and decrease complications during neonatal intubation.
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88
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Lautz AJ, Martin KC, Nishisaki A, Bonafide CP, Hales RL, Hunt EA, Nadkarni VM, Sutton RM, Boyer DL. Focused Training for the Handover of Critical Patient Information During Simulated Pediatric Emergencies. Hosp Pediatr 2018. [PMID: 29514852 DOI: 10.1542/hpeds.2017-0173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Miscommunication has been implicated as a leading cause of medical errors, and standardized handover programs have been associated with improved patient outcomes. However, the role of structured handovers in pediatric emergencies remains unclear. We sought to determine if training with an airway, breathing, circulation, situation, background, assessment, recommendation handover tool could improve the transmission of essential patient information during multidisciplinary simulations of critically ill children. METHODS We conducted a prospective, randomized, intervention study with first-year pediatric residents at a quaternary academic children's hospital. Baseline and second handovers were recorded for residents in the intervention group (n = 12) and residents in the control group (n = 8) during multidisciplinary simulations throughout the academic year. The intervention group received handover education after baseline handover observation and a cognitive aid before second handover observation. Audio-recorded handovers were scored by using a Delphi-developed assessment tool by a blinded rater. RESULTS There was no difference in baseline handover scores between groups (P = .69), but second handover scores were significantly higher in the intervention group (median 12.5 [interquartile range 12-13] versus median 7.5 [interquartile range 6-8] in the control group; P < .01). Trained residents were more likely to include a reason for the call (P < .01), focused history (P = .02), and summative assessment (P = .03). Neither timing of the second observation in the academic year nor duration between first and second observation were associated with the second handover scores (both P > .5). CONCLUSIONS Structured handover training and provision of a cognitive aid may improve the inclusion of essential patient information in the handover of simulated critically ill children.
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89
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Mokhateb-Rafii T, Bakar A, Gangadharan S, Gradidge E, Tellez D, Ruppe M, Nadkarni V, Nishisaki A. 327: RISK OF TRACHEAL INTUBATION ADVERSE EVENTS ASSOCIATED WITH HYPOXEMIA IN CHILDREN WITH HEART DISEASE. Crit Care Med 2018. [DOI: 10.1097/01.ccm.0000528346.24992.c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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90
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Glater-Welt L, Haddad D, Esperanza M, Sweberg T, Kessel A, Bakar A, Nishisaki A, Gangadharan S. 1327: CRM-BASED “TAKEOFF” SCRIPT REDUCES ESOPHAGEAL INTUBATIONS IN A MULTIDISCIPLINARY PICU. Crit Care Med 2018. [DOI: 10.1097/01.ccm.0000529330.17231.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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91
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Whalen AM, Boyer DL, Nishisaki A. Checklist-Based Assessment of Procedural Skills: A Missing Piece in the Link between Medical Education Interventions and Patient Outcomes. J Pediatr 2017; 188:11-13. [PMID: 28595763 DOI: 10.1016/j.jpeds.2017.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 05/15/2017] [Indexed: 11/19/2022]
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92
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Grunwell JR, Kamat PP, Miksa M, Krishna A, Walson K, Simon D, Krawiec C, Breuer R, Lee JH, Gradidge E, Tarquinio K, Shenoi A, Shults J, Nadkarni V, Nishisaki A. Trend and Outcomes of Video Laryngoscope Use Across PICUs. Pediatr Crit Care Med 2017; 18:741-749. [PMID: 28492404 PMCID: PMC6317345 DOI: 10.1097/pcc.0000000000001175] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Video (indirect) laryngoscopy is used as a primary tracheal intubation device for difficult airways in emergency departments and in adult ICUs. The use and outcomes of video laryngoscopy compared with direct laryngoscopy has not been quantified in PICUs or cardiac ICUs. DESIGN Retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from July 2010 to June 2015. SETTING Thirty-six PICUs/cardiac ICUs across the United States, Canada, Japan, New Zealand, and Singapore. PATIENTS Any patient admitted to a PICU or a pediatric cardiac ICU and undergoing tracheal intubation. INTERVENTIONS Use of direct laryngoscopy versus video laryngoscopy for tracheal intubation. MEASUREMENTS AND MAIN RESULTS There were 8,875 tracheal intubations reported in the National Emergency Airway Registry for Children database, including 7,947 (89.5%) tracheal intubations performed using direct laryngoscopy and 928 (10.5%) tracheal intubations performed using video laryngoscopy. Wide variability in video laryngoscopy use exists across PICUs (median, 2.6%; range, 0-55%). Video laryngoscopy was more often used in older children (p < 0.001), in children with history of a difficult airway (p = 0.01), in children intubated for ventilatory failure (p < 0.001), and to facilitate the completion of an elective procedure (p = 0.048). After adjusting for patient-level covariates, a secular trend, and site-level variance, the use of video laryngoscopy significantly increased over a 5-year period compared with fiscal year 2011 (odds ratio, 6.7; 95% CI, 1.7-26.8 for fiscal year 2014 and odds ratio, 11.2; 95% CI, 3.2-38.9 for fiscal year 2015). The use of video laryngoscopy was independently associated with a lower occurrence of tracheal intubation adverse events (adjusted odds ratio, 0.57; 95% CI, 0.42-0.77; p < 0.001) but not with a lower occurrence of severe tracheal intubation adverse events (adjusted odds ratio, 0.86; 95% CI, 0.56-1.32; p = 0.49) or fewer multiple attempts at endotracheal intubation (adjusted odds ratio, 0.93; 95% CI, 0.71-1.22; p = 0.59). CONCLUSIONS Using National Emergency Airway Registry for Children data, we described patient-centered adverse outcomes associated with video laryngoscopy compared with direct laryngoscopy for tracheal intubation in the largest reported international cohort of children to date. Data from this study may be used to design sufficiently powered prospective studies comparing patient-centered outcomes for video laryngoscopy versus direct laryngoscopy during endotracheal intubation.
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93
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Parker MM, Nuthall G, Brown C, Biagas K, Napolitano N, Polikoff LA, Simon D, Miksa M, Gradidge E, Lee JH, Krishna AS, Tellez D, Bird GL, Rehder KJ, Turner DA, Adu-Darko M, Nett ST, Derbyshire AT, Meyer K, Giuliano J, Owen EB, Sullivan JE, Tarquinio K, Kamat P, Sanders RC, Pinto M, Bysani GK, Emeriaud G, Nagai Y, McCarthy MA, Walson KH, Vanderford P, Lee A, Bain J, Skippen P, Breuer R, Tallent S, Nadkarni V, Nishisaki A. Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes. Pediatr Crit Care Med 2017; 18:310-318. [PMID: 28198754 PMCID: PMC5554859 DOI: 10.1097/pcc.0000000000001074] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality. STUDY DESIGN Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%. SETTING PICUs participating in NEAR4KIDS. PATIENTS All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed. MEASUREMENTS AND MAIN RESULTS Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58-229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1-7 yr and 18% for 8-17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4-21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24-2.60; p = 0.002), after adjusted for patient confounders. CONCLUSIONS Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.
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94
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Napolitano N, Nishisaki A, Buffman HS, Leffelman J, Maltese MR, Nadkarni VM. Redesign of an Open-System Oxygen Face Mask With Mainstream Capnometer for Children. Respir Care 2016; 62:70-77. [PMID: 28003555 DOI: 10.4187/respcare.04751] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Partial pressure of end-tidal carbon dioxide (PETCO2 ) monitoring in children is important to detect apnea or hypopnea early to intervene before hypoxemia develops. Monitoring PETCO2 in children without a tracheal tube is challenging. To improve PETCO2 measurement accuracy in a commercially available mask with a mainstream CO2 detector, we implemented design changes with deform-and-hold shaping technology and anterior-posterior adjustment of the expiratory gas flow cup. METHODS Two sizes of redesigned face masks (small for 7-20 kg, medium for 10-40 kg) were evaluated. Initial bench testing used a simulator modeling a spontaneously breathing infant and child with a natural airway. An infant/child manikin head was connected to the breathing lung simulator. A mass flow controller provided expiratory CO2. Mask fit was then evaluated on healthy human subjects to identify anatomical features associated with good fit, defined as square shape capnography waveform during expiration. A 3-dimensional digital scan was used to quantify anatomical features. The gaps between face mask rims and facial surface were manually measured. RESULTS Bench testing revealed a PETCO2 difference of 3.4 ± 1.5 mm Hg between a measured PETCO2 by the redesigned mask and CO2 concentration at trachea, as compared with 6.7 ± 6.2 mm Hg between PETCO2 measured by nasal cannula and trachea (P < .001). In the human mask fit study, 35 children (13 ± 4 kg) with the small mask and 38 (24 ± 8 kg) with the medium mask were evaluated. Capnography tracing was successfully obtained in 86% of the small and 100% of the medium masks. In children with small-size masks, the gap between the face mask rim and the child's face was not statistically different among those with good mask fit and without (1.0 ± 1.5 mm vs 1.4 ± 1.9 mm, P = .73). CONCLUSIONS PETCO2 measurement by a redesigned open-system face mask with a mainstream CO2 detector was accurate in the bench setting. The redesigned face mask can attain good mask fit and accurate capnography tracings in the majority of infants and children.
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Auerbach M, Whitfill T, Gawel M, Kessler D, Walsh B, Gangadharan S, Hamilton MF, Schultz B, Nishisaki A, Tay KY, Lavoie M, Katznelson J, Dudas R, Baird J, Nadkarni V, Brown L. Differences in the Quality of Pediatric Resuscitative Care Across a Spectrum of Emergency Departments. JAMA Pediatr 2016; 170:987-994. [PMID: 27570926 DOI: 10.1001/jamapediatrics.2016.1550] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The quality of pediatric resuscitative care delivered across the spectrum of emergency departments (EDs) in the United States is poorly described. In a recent study, more than 4000 EDs completed the Pediatric Readiness Survey (PRS); however, the correlation of PRS scores with the quality of simulated or real patient care has not been described. OBJECTIVE To measure and compare the quality of resuscitative care delivered to simulated pediatric patients across a spectrum of EDs and to examine the correlation of PRS scores with quality measures. DESIGN, SETTING, AND PARTICIPANTS This prospective multicenter cohort study evaluated 58 interprofessional teams in their native pediatric or general ED resuscitation bays caring for a series of 3 simulated critically ill patients (sepsis, seizure, and cardiac arrest). MAIN OUTCOMES AND MEASURES A composite quality score (CQS) was measured as the sum of 4 domains: (1) adherence to sepsis guidelines, (2) adherence to cardiac arrest guidelines, (3) performance on seizure resuscitation, and (4) teamwork. Pediatric Readiness Survey scores and health care professional demographics were collected as independent data. Correlations were explored between CQS and individual domain scores with PRS. RESULTS Overall, 58 teams from 30 hospitals participated (8 pediatric EDs [PEDs], 22 general EDs [GEDs]). The mean CQS was 71 (95% CI, 68-75); PEDs had a higher mean CQS (82; 95% CI, 79-85) vs GEDs (66; 95% CI, 63-69) and outperformed GEDs in all domains. However, when using generalized estimating equations to estimate CQS controlling for clustering of the data, PED status did not explain a higher CQS (β = 4.28; 95% CI, -4.58 to 13.13) while the log of pediatric patient volume did explain a higher CQS (β = 9.57; 95% CI, 2.64-16.49). The correlation of CQS to PRS was moderate (r = 0.51; P < .001). The correlation was weak for cardiac arrest (r = 0.24; P = .07), weak for sepsis (ρ = 0.45; P < .001) and seizure (ρ = 0.43; P = .001), and strong for teamwork (ρ = 0.71; P < .001). CONCLUSIONS AND RELEVANCE This multicenter study noted significant differences in the quality of simulated pediatric resuscitative care across a spectrum of EDs. The CQS was higher in PEDs compared with GEDs. However, when controlling for pediatric patient volume and other variables in a multivariable model, PED status does not explain a higher CQS while pediatric patient volume does. The correlation of the PRS was moderate for simulation-based measures of quality.
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Conlon TW, Himebauch AS, Nishisaki A. The authors reply. Pediatr Crit Care Med 2016; 17:1016-1017. [PMID: 27705995 DOI: 10.1097/pcc.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ishizuka M, Rangarajan V, Sawyer TL, Napolitano N, Boyer DL, Morrison WE, Lockman JL, Berg RA, Nadkarni VM, Nishisaki A. The Development of Tracheal Intubation Proficiency Outside the Operating Suite During Pediatric Critical Care Medicine Fellowship Training: A Retrospective Cohort Study Using Cumulative Sum Analysis. Pediatr Crit Care Med 2016; 17:e309-16. [PMID: 27214591 PMCID: PMC5107314 DOI: 10.1097/pcc.0000000000000774] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Tracheal intubation is a core technical skill for pediatric critical care medicine fellows. Limited data exist to describe current pediatric critical care medicine fellow tracheal intubation skill acquisition through the training. We hypothesized that both overall and first-attempt tracheal intubation success rates by pediatric critical care medicine fellows improve over the course of training. DESIGN Retrospective cohort study at a single large academic children's hospital. MATERIALS AND METHODS The National Emergency Airway Registry for Children database and local QI database were merged for all tracheal intubations outside the Operating Suite by pediatric critical care medicine fellows from July 2011 to January 2015. Primary outcomes were tracheal intubation overall success (regardless of number of attempts) and first attempt success. Patient-level covariates were adjusted in multivariate analysis. Learning curves for each fellow were constructed by cumulative sum analysis. RESULTS A total of 730 tracheal intubation courses performed by 33 fellows were included in the analysis. The unadjusted overall and first attempt success rates were 87% and 80% during the first 3 months of fellowship, respectively, and 95% and 73%, respectively, during the past 3 months of fellowship. Overall success, but not first attempt success, improved during fellowship training (odds ratio for each 3 months, 1.08; 95% CI, 1.01-1.17; p = 0.037) after adjusting for patient-level covariates. Large variance in fellow's tracheal intubation proficiency outside the operating suite was demonstrated with a median number of tracheal intubation equal to 26 (range, 19-54) to achieve a 90% overall success rate. All fellows who completed 3 years of training during the study period achieved an acceptable 90% overall tracheal intubation success rate. CONCLUSIONS Tracheal intubation overall success improved significantly during the course of fellowship; however, the tracheal intubation first attempt success rates did not. Large variance existed in individual tracheal intubation performance over time. Further investigations on a larger scale across different training programs are necessary to clarify intensity and duration of the training to achieve tracheal intubation procedural competency.
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Lee JH, Turner DA, Kamat P, Nett S, Shults J, Nadkarni VM, Nishisaki A. The number of tracheal intubation attempts matters! A prospective multi-institutional pediatric observational study. BMC Pediatr 2016; 16:58. [PMID: 27130327 PMCID: PMC4851769 DOI: 10.1186/s12887-016-0593-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 04/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of multiple tracheal intubation (TI) attempts on outcomes in critically ill children with acute respiratory failure is not known. The objective of our study is to determine the association between number of TI attempts and severe desaturation (SpO2 < 70 %) and adverse TI associated events (TIAEs). METHODS We performed an analysis of a prospective multicenter TI database (National Emergency Airway Registry for Children: NEAR4KIDS). Primary exposure variable was number of TI attempts trichotomized as one, two, or ≥3 attempts. Estimates were adjusted for history of difficult airway, upper airway obstruction, and age. We included all children with initial TI performed with direct laryngoscopy for acute respiratory failure between 7/2010-3/2013. Our main outcome measures were desaturation (<80 % during TI attempt), severe desaturation (<70 %), adverse and severe TIAEs (e.g., cardiac arrest, hypotension requiring treatment). RESULTS Of 3382 TIs, 2080(65 %) were for acute respiratory failure. First attempt success was achieved in 1256/2080(60 %), second attempt in 503/2080(24 %), and ≥3 attempts in 321/2080(15 %). Higher number of attempts was associated with younger age, history of difficult airway, signs of upper airway obstruction, and first provider training level. The proportion of TIs with desaturation increased with increasing number of attempts (1 attempt:16 %, 2 attempts:36 %, ≥3 attempts:56 %, p < 0.001; adjusted OR for 2 attempts: 2.9[95 % CI:2.3-3.7]; ≥3 attempts: 6.5[95 % CI: 5.0-8.5], adjusted for patient factors). Proportion of TIs with severe desaturation also increased with increasing number of attempts (1 attempt:12 %, 2 attempts:30 %, ≥3 attempts:44 %, p < 0.001); adjusted OR for 2 attempts: 3.1[95 % CI:2.4-4.0]; ≥3 attempts: 5.7[95 % CI: 4.3-7.5] ). TIAE rates increased from 10 to 29 to 38 % with increasing number of attempts (p < 0.001); adjusted OR for 2 attempts: 3.7[95 % CI:2.9-4.9] ; ≥3 attempts: 5.5[95 % CI: 4.1-7.4]. Severe TIAE rates went from 5 to 8 to 9 % (p = 0.008); adjusted OR for 2 attempts: 1.6 [95 % CI:1.1-2.4]; ≥3 attempts: 1.8[95 % CI:1.1-2.8]. CONCLUSIONS Number of TI attempts was associated with desaturations and increased occurrence of TIAEs in critically ill children with acute respiratory failure. Thoughtful attention to initial provider as well as optimal setting/preparation is important to maximize the chance for first attempt success and to avoid desaturation.
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Sanders RC, Nett ST, Davis KF, Parker MM, Bysani GK, Adu-Darko M, Bird GL, Cheifetz IM, Derbyshire AT, Emeriaud G, Giuliano JS, Graciano AL, Hagiwara Y, Hefley G, Ikeyama T, Jarvis JD, Kamat P, Krishna AS, Lee A, Lee JH, Li S, Meyer K, Montgomery VL, Nagai Y, Pinto M, Rehder KJ, Saito O, Shenoi AN, Taekema HC, Tarquinio KM, Thompson AE, Turner DA, Nadkarni VM, Nishisaki A. Family Presence During Pediatric Tracheal Intubations. JAMA Pediatr 2016; 170:e154627. [PMID: 26954533 DOI: 10.1001/jamapediatrics.2015.4627] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Family-centered care, which supports family presence (FP) during procedures, is now a widely accepted standard at health care facilities that care for children. However, there is a paucity of data regarding the practice of FP during tracheal intubation (TI) in pediatric intensive care units (PICUs). Family presence during procedures in PICUs has been advocated. OBJECTIVE To describe the current practice of FP during TI and evaluate the association with procedural and clinician (including physician, respiratory therapist, and nurse practitioner) outcomes across multiple PICUs. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study in which all TIs from July 2010 to March 2014 in the multicenter TI database (National Emergency Airway Registry for Children [NEAR4KIDS]) were analyzed. Family presence was defined as a family member present during TI. This study included all TIs in patients younger than 18 years in 22 international PICUs. EXPOSURES Family presence and no FP during TI in the PICU. MAIN OUTCOMES AND MEASURES The percentage of FP during TIs. First attempt success rate, adverse TI-associated events, multiple attempts (≥ 3), oxygen desaturation (oxygen saturation as measured by pulse oximetry <80%), and self-reported team stress level. RESULTS A total of 4969 TI encounters were reported. Among those, 81% (n = 4030) of TIs had documented FP status (with/without). The median age of participants with FP was 2 years and 1 year for those without FP. The average percentage of TIs with FP was 19% and varied widely across sites (0%-43%; P < .001). Tracheal intubations with FP (vs without FP) were associated with older patients (median, 2 years vs 1 year; P = .04), lower Paediatric Index of Mortality 2 score, and pediatric resident as the first airway clinician (23%, n = 179 vs 18%, n = 584; odds ratio [OR], 1.4; 95% CI, 1.2-1.7). Tracheal intubations with FP and without FP were no different in the first attempt success rate (OR, 1.00; 95% CI, 0.85-1.18), adverse TI-associated events (any events: OR, 1.06; 95% CI, 0.85-1.30 and severe events: OR, 1.04; 95% CI, 0.75-1.43), multiple attempts (≥ 3) (OR, 1.03; 95% CI, 0.82-1.28), oxygen desaturation (oxygen saturation <80%) (OR, 0.97; 95% CI, 0.80-1.18), or self-reported team stress level (OR, 1.09; 95% CI, 0.92-1.31). This result persisted after adjusting for patient and clinician confounders. CONCLUSIONS AND RELEVANCE Wide variability exists in FP during TIs across PICUs. Family presence was not associated with first attempt success, adverse TI-associated events, oxygen desaturation (<80%), or higher team stress level. Our data suggest that FP during TI can safely be implemented as part of a family-centered care model in the PICU.
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Crulli B, Loron G, Nishisaki A, Harrington K, Essouri S, Emeriaud G. Safety of paediatric tracheal intubation after non-invasive ventilation failure. Pediatr Pulmonol 2016; 51:165-72. [PMID: 26079189 DOI: 10.1002/ppul.23223] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 04/19/2015] [Accepted: 05/08/2015] [Indexed: 11/06/2022]
Abstract
CONTEXT Non-invasive ventilation (NIV) is increasingly used in pediatric intensive care units to limit the complications associated with intubation. However, NIV may fail, and the delay in initiating invasive ventilation may be associated with adverse outcomes. The objective of this retrospective study was to evaluate the safety of tracheal intubation after NIV failure. METHODS Consecutive tracheal intubation procedures were prospectively evaluated in our PICU from 01/2011 to 02/2012, as part of the National Emergency Airway Registry for Children (NEAR4KIDS) collaborative. The incidence of severe tracheal intubation associated events (TIAEs, including cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, malignant hyperthermia, pneumothorax, and pneumomediastinum) and severe desaturation (below 80% when pre-intubation saturation was greater than 94%) were recorded prospectively. NIV use before intubation was retrospectively assessed. RESULTS 100 consecutive intubation events were analyzed, 46 of which followed NIV failure. NIV exposed and non-exposed groups had different baseline characteristics, with lower weight, more frequent lower airway and lung disorder, and lower PIM2 score at admission in NIV failure patients (all P < 0.05). The nasal route for intubation was more frequent in NIV patients (P < 0.01). The incidence of severe TIAE or desaturation was 41% in the NIV failure group and 24% in primarily intubated patients (P = 0.09). CONCLUSION Complications occurred in 41% of intubations after NIV failure in this series. Further research is warranted to evaluate strategies to prevent these complications and to identify conditions in which intubation should not be delayed for a trial of NIV.
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