1
|
Thomas P, Kerrey B, Edmunds K, Dean P, Frey M, Boyd S, Geis G, Ahaus K, Zhang Y, Sobolewski B. Video-Based Study of the Progression of Pediatric Emergency Medicine Fellows' Tracheal Intubation Performance During Training. Pediatr Emerg Care 2024:00006565-990000000-00508. [PMID: 39173190 DOI: 10.1097/pec.0000000000003204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The lower clinical exposure of Pediatric Emergency Medicine (PEM) fellows to critical procedures may impede skill acquisition. We sought to determine the tracheal intubation learning curve of PEM fellows during training and compared PEM fellow success against standards for tracheal intubation success. METHODS This was a retrospective, video-based study of a cohort of PEM fellows at a single academic pediatric emergency department (PED). All forms of tracheal intubation were included (rapid sequence intubation and crash or no medication). The cohort consisted of 36 PEM fellows from all or part of 5 consecutive fellowship classes. Data were collected by structured review of both existing ceiling-mounted videos and the electronic medical record. The main outcome was PEM fellows' success on the first or second attempt. We used cumulative summation to generate tracheal intubation learning curves. We specifically assessed the proportion of PEM fellows who reached 1 of 4 thresholds for procedural performance: 90% and 80% predicted success on the first and the first or second attempt. RESULTS From July 2014 to June 2020, there were 610 patient encounters with at least 1 attempt at tracheal intubation. The 36 PEM fellows performed at least 1 attempt at tracheal intubation for 414 ED patient encounters (65%). Median patient age was 2.1 years (interquartile range, 0.4-8.1). The PEM fellows were successful on the first attempt for 276 patients (67%) and on the first or second attempt for 337 (81%). None of the 36 PEM fellows reached the 90% threshold for either first or second attempt success. Four fellows (11%) met the 80% threshold for first attempt success and 11 (31%) met the 80% threshold for first or second attempt success. CONCLUSIONS Despite performing the majority of attempts, PEM fellows often failed to reach the standard thresholds for performance of tracheal intubation. Clinical exposure alone is too low to ensure acquisition of airway skills.
Collapse
Affiliation(s)
| | | | | | | | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | | | | | - Karen Ahaus
- Division of Respiratory Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yin Zhang
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | | |
Collapse
|
2
|
Datta S, Sankar J, Pathak M, Tungal S, Kandasamy D, Dhochak N, Jat KR, Lodha R. Diagnostic accuracy of airway ultrasound in confirming the endotracheal tube depth in critically ill children. Am J Emerg Med 2024; 85:52-58. [PMID: 39232455 DOI: 10.1016/j.ajem.2024.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 07/08/2024] [Accepted: 08/08/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Chest X-ray, the established standard of confirming endotracheal tube (ETT) position, has important drawbacks including radiation exposure. Point-of-care airway ultrasound, which has been insufficiently studied in children, can overcome these problems. MATERIALS AND METHODS This was a prospective cross-sectional study done on children aged 2 months to 17 years undergoing intubation with cuffed ETT in the PICU. The ETT cuff was filled with saline and three ultrasonographic techniques were used- 1) Suprasternal (SS) method 2) Cricoid (CC) metho and 3) Tracheal ring (TR) method. Position of the ETT as determined by ultrasound and X-ray were compared. The main outcomes were sensitivity, specificity, and area under curve (AUC) for ultrasound-based methods vs. X-ray. For the TR method, concordance between the X-ray and ultrasound categories were taken. RESULTS Total 62 patients were enrolled. The sensitivity and specificity of SS method were 71% (95% CI: 57-83%) and 100% (40-100%). The CC distance method had an AUC of 0.94 (95% CI: 0.86, 1.0). In the TR method, 98% of correct position on X-ray were correctly classified by USG. The agreement between X-ray and ultrasound categories with the cuff between the first and third tracheal rings, was very good [kappa (95% CI): 0.87 (0.70, 1.00), p ≤0.001)]. CONCLUSION Bedside ultrasound is a good method to confirm ETT depth in children. The tracheal ring method had the best diagnostic accuracy and is easy to perform. The new method using cricoid cuff distance needs further validation in different ICU settings.
Collapse
Affiliation(s)
- Souraja Datta
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jhuma Sankar
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
| | - Mona Pathak
- Department of Biostatistics, Kalinga Institute of Medical Sciences, Bhubaneshwar, India
| | - Sagar Tungal
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Nitin Dhochak
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kana Ram Jat
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lodha
- Division of Pediatric Pulmonology and Intensive Care, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
3
|
Kaufmann J, Huber D, Engelhardt T, Kleine-Brueggeney M, Kranke P, Riva T, von Ungern-Sternberg BS, Fuchs A. [Airway management in neonates and infants : Recommendations according to the ESAIC/BJA guidelines]. DIE ANAESTHESIOLOGIE 2024; 73:473-481. [PMID: 38958671 PMCID: PMC11222175 DOI: 10.1007/s00101-024-01424-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Securing an airway enables the oxygenation and ventilation of the lungs and is a potentially life-saving medical procedure. Adverse and critical events are common during airway management, particularly in neonates and infants. The multifactorial reasons for this include patient-dependent, user-dependent and also external factors. The recently published joint ESAIC/BJA international guidelines on airway management in neonates and infants are summarized with a focus on the clinical application. The original publication of the guidelines focussed on naming formal recommendations based on systematically documented evidence, whereas this summary focusses particularly on the practicability of their implementation.
Collapse
Affiliation(s)
- Jost Kaufmann
- Kinderkrankenhaus der Kliniken der Stadt Köln gGmbH, Amsterdamer Str. 59, 50735, Köln, Deutschland.
- Fakultät für Gesundheit, Universität Witten/Herdecke, Witten, Deutschland.
| | - Dennis Huber
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Thomas Engelhardt
- Department of Anesthesiology, Montreal Children's Hospital, McGill University, Montreal, QC, Kanada
| | - Maren Kleine-Brueggeney
- Klinik für Kardioanästhesiologie und Intensivmedizin, Deutsches Herzzentrum der Charité (DHZC), Berlin, Deutschland
- Charité - Universitätsmedizin Berlin, korporatives Mitglied der Freien Universität Berlin und Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Peter Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Thomas Riva
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, WA, Australien
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australien
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, WA, Australien
- Perioperative Medicine Team, Perioperative Care Program, Telethon Kids Institute, Perth, WA, Australien
| | - Alexander Fuchs
- Universitätsklinik für Anästhesiologie und Schmerzmedizin, Inselspital, Universität Bern, Bern, Schweiz
| |
Collapse
|
4
|
Rebollar RE, Hierro PL, Fernández AMMA. Delayed Sequence Intubation in Children, Why Not? SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:117-124. [PMID: 38764564 PMCID: PMC11098273 DOI: 10.4103/sjmms.sjmms_612_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/08/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.
Collapse
Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
| | - Paula Lozano Hierro
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
| | | |
Collapse
|
5
|
Alsabri M, Abdelwahab OA, Elsnhory AB, Diab RA, Sabesan V, Ayyan M, McClean C, Alhadheri A. Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2024; 13:85. [PMID: 38475918 PMCID: PMC10935931 DOI: 10.1186/s13643-024-02500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Intubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting. METHODS We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively. RESULTS Fourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD = - 6.92, 95% CI [- 12.86, - 0.99], P = 0.02), intubation difficulty score (MD = - 0.62, 95% CI [- 0.86, - 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05). CONCLUSION In emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.
Collapse
Affiliation(s)
- Mohammed Alsabri
- Department of Emergency Medicine, Al-Thawra Modern General Teaching Hospital, Sana'a City, Yemen.
| | | | | | | | | | | | | | - Ayman Alhadheri
- Michigan State University College of Osteopathic Medicine, East Lansing, USA
| |
Collapse
|
6
|
Wolfgang M, Labudde EJ, Ruff K, Geis G, Frey M, Boyd S, Harun N, Kerrey BT. Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department. Pediatr Emerg Care 2024; 40:203-207. [PMID: 37039447 DOI: 10.1097/pec.0000000000002939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVES The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork. METHODS This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool. RESULTS We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007). CONCLUSIONS Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.
Collapse
Affiliation(s)
- Matthew Wolfgang
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Emily J Labudde
- Pediatric Residency Program, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kristen Ruff
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Mary Frey
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephanie Boyd
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nusrat Harun
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | |
Collapse
|
7
|
Edmunds KJ, Shah A, Geis GL, Kerrey BT, Klein G, DeBra R, Zhang Y, Ahaus K, Boyd S, Thomas P, Dean P. Rapid cycle deliberate practice to improve airway skills and performance of trainees in a pediatric emergency department. AEM EDUCATION AND TRAINING 2024; 8:AET210928. [PMID: 38235393 PMCID: PMC10790190 DOI: 10.1002/aet2.10928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 01/19/2024]
Abstract
Objective The study objective was to determine the effect of a rapid cycle deliberate practice (RCDP) program on simulated and actual airway skills by pediatric emergency medicine (PEM) fellows. Methods We designed and implemented a 12-month RCDP airway skills curriculum for PEM fellows at an academic pediatric institution. The curriculum was designed using airway training literature, RCDP principals, and internal quality assurance airway video review program. Simulation training scenarios increased in complexity throughout the curriculum. PEM fellows participated in monthly sessions. Two PEM faculty facilitated the sessions, utilizing a step-by-step objective structured clinical evaluation (OSCE)-style tool for each scenario. Data were collected for all four levels of the Kirkpatrick Model of Training Evaluation-participant response (reaction, pre-post session survey), skills performance in the simulation setting (learning, pre-post OSCE), skills performance for actual patients (behavior, video review), and patient outcomes (results, video review). Results During the study period (August 2021 to June 2022), 13 PEM fellows participated in 112 sessions (mean nine sessions per fellow). PEM fellows reported improved comfort in all domains of airway management, including intubation performance. Participant OSCE scores improved posttraining (pretraining median score for trainees 57 [IQR 57-59], posttraining median 61 [IQR 61-62], p = 0.0005). Over the 12 months, PEM fellows performed 45 intubation attempts in the pediatric emergency department (median patient age 4 years [IQR 1-9 years]). Compared to a 5-year historical cohort, participants had higher first-pass success (87% vs. 71%, p = 0.028) and shorter attempt duration (22 s vs. 29 s, p = 0.018). There was no significant difference in the frequency of oxyhemoglobin desaturation in the training period versus the historical period (7% vs. 15%, p = 0.231). Conclusions At multiple levels of educational outcomes, including participant behavior and patient outcomes, an RCDP program was associated with improved airway skills and performance of PEM fellows.
Collapse
Affiliation(s)
- Katherine J. Edmunds
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati, College of MedicineCincinnatiOhioUSA
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's HospitalUniversity of California San DiegoSan DiegoCaliforniaUSA
| | - Gary L. Geis
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati, College of MedicineCincinnatiOhioUSA
- The Center for Simulation and ResearchCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin T. Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati, College of MedicineCincinnatiOhioUSA
| | - Gina Klein
- The Center for Simulation and ResearchCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Rebecca DeBra
- The Center for Simulation and ResearchCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Yin Zhang
- Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Karen Ahaus
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Stephanie Boyd
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Phillip Thomas
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati, College of MedicineCincinnatiOhioUSA
| |
Collapse
|
8
|
Solan T, Cudini D, Humar M, Forsyth N, Meadley B, St Clair T, Hodge D, Smith K, Babl FE, Long E. Characteristics of paediatric pre-hospital intubation by Intensive Care Paramedics. Emerg Med Australas 2023; 35:754-758. [PMID: 37019689 DOI: 10.1111/1742-6723.14207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 03/01/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVES Emergency intubation in children is an infrequent procedure both in the pre-hospital and hospital setting. The anatomical, physiological and situational challenges together with limited clinician exposure can make this a difficult procedure with high risk of adverse events. The aim of this collaborative study between a state-wide ambulance service and a tertiary children's hospital was to describe the characteristics of pre-hospital paediatric intubations by Intensive Care Paramedics. METHODS We conducted a retrospective review of state-wide ambulance service electronic patient care records (ePCRs) in Victoria, Australia, population: 6.5 million. Children aged 0-18 years who were attended by paramedics over a 12-month period that required advanced airway management were analysed for demographics and first-pass success rate. RESULTS Paramedics attended 2674 cases aged 0-18 years over the 12-month study period who received basic or advanced airway management. A total of 78 cases required advanced airway management. The median age of patients was 12 years (interquartile range 3-16) and most were male (60.2%). Sixty-eight patients (87.5%) were intubated successfully on the first attempt, first-pass success was lowest in children <1 year of age. The most common indications for pre-hospital intubation were closed head injury and cardiac arrest. It was not possible to report complication rates because of incomplete documentation. CONCLUSION Pre-hospital intubation in children is performed infrequently in an extremely unwell patient group. Continued high-level paramedic training is required to prevent adverse events and ensure patient safety.
Collapse
Affiliation(s)
- Tom Solan
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Daniel Cudini
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Matthew Humar
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Nathan Forsyth
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Ben Meadley
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Toby St Clair
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Darren Hodge
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
| | - Franz E Babl
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elliot Long
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Victoria, Australia
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia
- Departments of Paediatrics and Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
9
|
Dean P, Geis G, Hoehn EF, Lautz AJ, Edmunds K, Shah A, Zhang Y, Frey M, Boyd S, Nagler J, Miller KA, Neubrand TL, Cabrera N, Kopp TM, Wadih E, Kannikeswaran N, VanDeWall A, Hewett Brumberg EK, Donoghue A, Palladino L, O'Connell KJ, Mazzawi M, Tam DCF, Murray M, Kerrey B. High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence. Resuscitation 2023; 190:109875. [PMID: 37327848 DOI: 10.1016/j.resuscitation.2023.109875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.
Collapse
Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Gary Geis
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Erin F Hoehn
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Division of Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - Andrew J Lautz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Joshua Nagler
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Kelsey A Miller
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Tara L Neubrand
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States.
| | - Natasha Cabrera
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Tara M Kopp
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Esper Wadih
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Audrey VanDeWall
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Elizabeth K Hewett Brumberg
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Aaron Donoghue
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Lauren Palladino
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Malek Mazzawi
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Derek Chi Fung Tam
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Matthew Murray
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Benjamin Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| |
Collapse
|
10
|
Goodier R, Partyka C, Moore N, Middleton P, Abdullah Q. Mixed-methods pilot study exploring the influence of the novel Paediatric Anaesthetic Drug Solution tool on clinician cognitive load during simulated paediatric rapid sequence intubation in the emergency department. J Paediatr Child Health 2023. [PMID: 37067808 DOI: 10.1111/jpc.16396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 02/13/2023] [Accepted: 03/21/2023] [Indexed: 04/18/2023]
Abstract
AIM Rapid sequence intubation (RSI) in children is a low-incidence, high-risk event associated with cognitive overload and potential errors producing unfavourable outcomes. Cognitive aids, such as charts, algorithms and flow diagrams, are prompts that externalise and structure mental processes to reduce cognitive load, thereby reducing errors. The Paediatric Anaesthetic Emergency Drug Solution (PAEDS) approach combines a colour-coded chart and medication box with a simplified mathematical system of volume-based dosing; the effect of which on cognitive load during a simulated RSI has not previously been described. METHODS A randomised, cross-over trial was conducted with 26 multi-disciplinary emergency medicine clinicians (doctors and nurses) allocated to four groups, performing four high-fidelity RSI simulations, two mandating the use of the PAEDS approach. This mixed methods study followed the pragmatic ontology using grounded theory methodology. Qualitative data were collected from nine individual interviews by a process of thematic analysis via an inductive approach, to allow for appropriate open and axial coding to occur. Quantitative data collected included cognitive loading using the raw NASA-Task Load Index as well as time to intubation and drug dosage details to assess for safety. RESULTS Qualitative results showed that the PAEDS approach reduced cognitive loading through the use of both the labelled medication box and colour-coded medication charts. The PAEDS approach also showed improved perceived time pressure without feeling rushed, and with no recorded drug errors. Differences in the quantitative data for total cognitive load, error and time were not statistically significant, likely due to sample size. CONCLUSION The PAEDS approach is a multifaceted system which is not inferior to current practice, with some components described as an improvement. Further research on a larger sample size needs to be conducted to assess the aspects of the PAEDS approach both collectively and independently.
Collapse
Affiliation(s)
- Robyn Goodier
- Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Medical Education, School of Medicine, University of Dundee, Dundee, UK
| | - Christopher Partyka
- Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nicholas Moore
- Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- South Western Emergency Research Institute, Ingham Institute, Sydney, New South Wales, Australia
| | - Paul Middleton
- Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- South Western Emergency Research Institute, Ingham Institute, Sydney, New South Wales, Australia
| | - Qabirul Abdullah
- Centre for Medical Education, School of Medicine, University of Dundee, Dundee, UK
| |
Collapse
|
11
|
Miller KA, Auerbach M, Bin SS, Donoghue A, Kerrey BT, Mittiga MR, D'Ambrosi G, Monuteaux MC, Marchese A, Nagler J. Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation. AEM EDUCATION AND TRAINING 2023; 7:e10846. [PMID: 36936084 PMCID: PMC10014969 DOI: 10.1002/aet2.10846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 06/18/2023]
Abstract
Background Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Methods Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Results Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. Conclusions This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.
Collapse
Affiliation(s)
- Kelsey A. Miller
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Steven S. Bin
- Departments of Pediatrics and Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Aaron Donoghue
- Department of Anesthesiology and Critical CarePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Benjamin T. Kerrey
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | | | | | - Ashley Marchese
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Joshua Nagler
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| |
Collapse
|
12
|
Liu Y, Ma W, Liu J. Applications of Airway Ultrasound for Endotracheal Intubation in Pediatric Patients: A Systematic Review. J Clin Med 2023; 12:jcm12041477. [PMID: 36836012 PMCID: PMC9961112 DOI: 10.3390/jcm12041477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Abstract
Endotracheal intubation is a challenging procedure for pediatric patients. Airway ultrasound as a new technology is suitable for aiding this process, but its diagnostic value remains unclear. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Chinese biomedical literature database to summarize specific applications of airway ultrasound in each step of endotracheal intubation in pediatric patients. Diagnostic accuracy and 95% confidence interval were used as outcomes. In total, 33 studies (6 randomized controlled trials and 27 diagnostic studies) with 1934 airway ultrasound examinations were included. Population included neonates, infants, and older children. Airway ultrasound could be used to determine the endotracheal tube size and confirm endotracheal intubation and intubation depth; the diagnostic accuracy for all these factors was 23.3-100%, 90.6-100%, and 66.7-100%, respectively. Furthermore, the accuracy of airway ultrasound in predicting endotracheal tube size was consistently higher than traditional methods, such as height formula, age formula, and the width of the little finger. In conclusion, airway ultrasound has unique advantages for confirming successful endotracheal intubation in pediatric patients, and it may become an effective auxiliary tool in this field. There is a need to develop a unified airway ultrasound protocol to conduct clinical trials and practice in the future.
Collapse
Affiliation(s)
- Yijun Liu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
- The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Wei Ma
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
- The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin Liu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
- The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu 610041, China
- Correspondence:
| |
Collapse
|
13
|
Pediatric Trauma. Emerg Med Clin North Am 2023; 41:205-222. [DOI: 10.1016/j.emc.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
14
|
Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand T, Goldman MP, Prieto MM, Wing R, Breuer R, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes. Ann Emerg Med 2023; 81:113-122. [PMID: 36253297 DOI: 10.1016/j.annemergmed.2022.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.
Collapse
Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
| | | | - Andrew F Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Phillip M Thomas
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Tara Neubrand
- Department of Emergency Medicine - Pediatric Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, CT
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, RI
| | - Ryan Breuer
- Department of Pediatrics - Pediatric Critical Care, Oishei Children's Hospital, Buffalo, NY
| | - Jenn D'Mello
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| |
Collapse
|
15
|
Maek T, Fochtmann U, von Loewenich A, Jungbluth P, Zimmermann W, Lefering R, Lendemans S, Hussmann B. Is prehospital intubation of severely injured children in accordance with guidelines? BMC Emerg Med 2022; 22:194. [PMID: 36474145 PMCID: PMC9724279 DOI: 10.1186/s12873-022-00750-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The current German S3 guideline for polytrauma lists five criteria for prehospital intubation: apnea, severe traumatic brain injury (GCS ≤8), severe chest trauma with respiratory failure, hypoxia, and persistent hemodynamic instability. These guideline criteria, used in adults in daily practice, have not been previously studied in a collection of severely injured children. The aim of this study was to assess the extent to which the criteria are implemented in clinical practice using a multivariate risk analysis of severely injured children. METHODS Data of 289,698 patients from the TraumaRegister DGU® were analyzed. Children meeting the following criteria were included: Maximum Abbreviated Injury Scale 3+, primary admission, German-speaking countries, years 2008-2017, and declaration of intubation. Since children show age-dependent deviating physiology, four age groups were defined (years old: 0-2; 3-6; 7-11; 12-15). An adult collective served as a control group (age: 20-50). After a descriptive analysis in the first step, factors leading to prehospital intubation in severely injured children were analyzed with a multivariate regression analysis. RESULTS A total of 4489 children met the inclusion criteria. In this cohort, young children up to 2 years old had the significantly highest injury severity (Injury Severity Score: 21; p ≤ 0.001). Falls from both high (> 3 m) and low heights (< 3 m) were more common in children than in adults. The same finding applied to the occurrence of severe traumatic brain injury. When at least one intubation criterion was formally present, the group up to 6 years old was least likely to actually be intubated (61.4%; p ≤ 0.001). Multivariate regression analysis showed that Glasgow Coma Scale score ≤ 8 in particular had the greatest influence on intubation (odds ratio: 26.9; p ≤ 0.001). CONCLUSIONS The data presented here show for the first time that the existing criteria in the guideline for prehospital intubation are applied in clinical practice (approximately 70% of cases), compared to adults, in the vast majority of injured children. Although severely injured children still represent a minority of all injured patients, future guidelines should focus more on them and address them in a specialized manner.
Collapse
Affiliation(s)
- Teresa Maek
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Ulrike Fochtmann
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Anna von Loewenich
- grid.410718.b0000 0001 0262 7331Department of Pediatrics 1, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Pascal Jungbluth
- grid.14778.3d0000 0000 8922 7789Department of Orthopedics and Trauma Surgery, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Werner Zimmermann
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Rolf Lefering
- grid.412581.b0000 0000 9024 6397Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimer Straße 200, 51109 Cologne, Germany
| | - Sven Lendemans
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany ,grid.5718.b0000 0001 2187 5445University of Duisburg-Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Bjoern Hussmann
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany ,grid.14778.3d0000 0000 8922 7789Department of Orthopedics and Trauma Surgery, University Hospital Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| |
Collapse
|
16
|
Cao Y, Jiang L, Zhang Y, Yao W, Chen Y, Dai Z. An optimal tracheal tube preshaping strategy for endotracheal intubation using video laryngoscopy: a randomized controlled trial. J Clin Monit Comput 2022; 36:1629-1634. [PMID: 35083623 DOI: 10.1007/s10877-022-00806-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 01/03/2022] [Indexed: 11/28/2022]
Abstract
Although video laryngoscopy solves the problem of glottis exposure, it is difficult to deliver the tube to the glottic opening when the tracheal tube is unevenly shaped. This study aimed to compare the effects of different tube shapes on the first-pass success (FPS) rate in patients undergoing video laryngoscopy-assisted tracheal intubation. Three hundred patients above 18 years of age who underwent general anaesthesia and required endotracheal intubation were included in the study. The participants were randomly allocated to three groups with 100 participants in each group as follows: Group A, video laryngoscopes with a self-equipped stylet are used for tube preshaping; Group B: curvature of the video laryngoscope blade is modelled for tube preshaping; Group C: tube preshaping angle is consistent with the video laryngoscope blade, and the bending point is set 1 cm above the tracheal tube cuff. The primary outcome was FPS rates. The secondary outcomes included time to tracheal intubation, haemodynamic responses and adverse events. No significant differences in patient characteristics or airway assessments were noted (P > 0.05). Compared with Groups A, Group B and Group C exhibited a higher FPS rate (68% vs. 86% vs. 92%; P < 0.001). However, there is no significant difference in FPS rate between Group B and Group C (P > 0.05). And the time to tracheal intubation in Group C was significantly less than that in Group A and Group B (22.21 ± 4.01 vs. 19.92 ± 4.11 vs. 17.71 ± 3.47; P < 0.001). The straight-to-cuff stylet preshape angulation of curvature of the blade could provide a higher FPS rate and shorter time to tracheal intubation during video laryngoscopy-assisted endotracheal intubation. Trial registration: Chinese Clinical Trial Registry, ChiCTR1900026019.
Collapse
Affiliation(s)
- Ya Cao
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Lianxiang Jiang
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Yan Zhang
- Department of Anaesthesia, Tongling People's Hospital, Tongling, Anhui, China
| | - Weidong Yao
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Yongquan Chen
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Zeping Dai
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China.
| |
Collapse
|
17
|
Hagiwara Y, Goto T, Ohnishi S, Miyamoto D, Ikeyama Y, Matsunami K, Hasegawa K. Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study. Acute Med Surg 2022; 9:e798. [PMID: 36203851 PMCID: PMC9525619 DOI: 10.1002/ams2.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 09/14/2022] [Indexed: 11/09/2022] Open
Abstract
Aim Tracheal intubation is a vital resuscitation procedure in the pediatric emergency department (ED). Despite its importance, little is known about the current status of emergency airway management in Japan. In this context, we aimed to investigate the airway management characteristics-particularly the location, patient, and provider factors-in the pediatric ED. Methods We conducted a multicenter, prospective study of five pediatric EDs in Japan from October 2018 to June 2020. The study included all children (aged ≤18 years) who underwent intubation at the pre-ED or ED setting by physicians and those who were transferred from the ED to the operation room (OR) or pediatric intensive care unit (PICU) for intubation. We described the airway management characteristics according to the location, patient, and provider factors. Results Of 231 children, 9 (4%) were transferred to the OR or PICU for airway management. Among the remaining 222 children, 45 were intubated at the pre-ED setting and 177 were intubated in the ED. The overall first-attempt success rate was 72%, with the rate varying by location, patient, and provider factors-for example, 68% at the pre-ED setting, 67% for children <2 years, 56% for children with airway-related anatomical anomalies, and 61% with intubation by a resident physician. Intubation-related adverse events were observed in 17%, most of which were hypoxemia (14%). Conclusions Based on data from a multicenter prospective study, the overall first-attempt intubation success rate in pediatric EDs in Japan was 72%, with large variations by location, patient, and provider factors.
Collapse
Affiliation(s)
- Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care MedicineTokyo Metropolitan Children's Medical CenterTokyoJapan
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public HealthThe University of TokyoTokyoJapan
| | - Shima Ohnishi
- Division of Emergency and Transport ServicesNational Center for Child Health and DevelopmentTokyoJapan
| | - Daisuke Miyamoto
- Department of Pediatric Emergency MedicineSaitama Children's Medical CenterSaitamaJapan
| | - Yuki Ikeyama
- Department of Pediatric Emergency MedicineAichi Children's Health and Medical CenterObu‐shi, AichiJapan
| | - Kunihiro Matsunami
- Department of PediatricsGifu Prefectural General Medical CenterGifuJapan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMA
| | | |
Collapse
|
18
|
Lee JY, Lee SU, Son MH, Park JW, Jung JY, Kim JH. Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea. Yonsei Med J 2022; 63:767-773. [PMID: 35914759 PMCID: PMC9344268 DOI: 10.3349/ymj.2022.63.8.767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/01/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Rapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications. MATERIALS AND METHODS This multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted. RESULTS A total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p<0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p<0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p<0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120-1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093-4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257-11.626). CONCLUSION RSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.
Collapse
Affiliation(s)
- Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Seoul, Korea
| | - Meong Hi Son
- Department of Pediatrics, Samsung Medical Center, Seoul, Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea.
| |
Collapse
|
19
|
Zaki HA, Shalik N, Shaban E, Bashir K, Iftikhar H, Mohamed Khair Y, Abdelrahim MG, Fayed M, Hendy M, Salem EED, Elmoheen A. An Analytical Comparison Between Ketamine Alone and a Combination of Ketamine and Propofol (Ketofol) for Procedural Sedation and Analgesia From an Emergency Perspective: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e27318. [PMID: 36042988 PMCID: PMC9411697 DOI: 10.7759/cureus.27318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/06/2022] Open
Abstract
Procedural sedation and analgesia (PSA) is a treatment approach involving treating patients with agents with dissociative, sedative, or analgesic properties to suppress their consciousness to variable levels. Ketamine and propofol have been used historically for PSA. Because they each have their demerits, it was postulated that combining both drugs (ketofol) would result in a mixture with additive properties and lessen or eliminate the demerits attributed to each drug. The primary objective of this systematic review and meta-analysis is to compare ketamine alone and a combination of ketamine and propofol (ketofol) for procedural sedation and analgesia from an emergency perspective. A systematic search was conducted on published studies from the databases of Scopus, ScienceDirect, PubMed, Google Scholar, APA PsycInfo, and the Cochrane Central Register of Controlled Trial (CENTRAL) until July 2022. The articles that were published on the online databases were authored between January 2007 and 2018. The selected papers were scanned and examined to check whether they met the eligibility criteria for the study. The search produced six articles that were included in the systematic review and meta-analysis. All six articles that passed the eligibility criteria were viable for the analysis. All the trials focused on the effectiveness of ketofol versus ketamine for PSA from an emergency perspective. Ketofol was found to be safe and more effective in comparison to ketamine for PTA.
Collapse
|
20
|
Edmunds K, Pierpoint S, Frey M, Ahaus K, Boyd S, Shah A, Zhang Y, Kerrey B. Fraction of Expired Oxygen as a Measure of Preoxygenation Prior to Rapid Sequence Intubation in the Pediatric Emergency Department. J Emerg Med 2022; 63:62-71. [PMID: 35933262 DOI: 10.1016/j.jemermed.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/08/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pulse oximetry (SpO2) is a flawed measure of adequacy of preoxygenation prior to intubation. The fraction of expired oxygen (FeO2) is a promising but understudied alternative. OBJECTIVE To investigate FeO2 as a measure of preoxygenation prior to intubation in a pediatric emergency department. METHODS We conducted a prospective, observational study of patients 18 and younger. We collected data using video review, and FeO2 was measured via inline sampling. The main outcomes were FeO2 and SpO2 at the start of preoxygenation, end of preoxygenation/start of intubation attempt, and the end of intubation attempt. We compared FeO2 and SpO2 at the end of preoxygenation for patients with and without oxyhemoglobin desaturation. RESULTS We enrolled 85 of 88 eligible patients during the 14-month study period. FeO2 data were available at the start of preoxygenation for 53 of 85 patients (62%), and for the end of preoxygenation for 59 of 85 patients (69%). Median FeO2 at the start and end of preoxygenation was 90% (interquartile range [IQR] 88, 92) and 90% (IQR 88, 92). Median SpO2 at the start and end of preoxygenation was 100% (IQR 100, 100). There were 11 episodes of desaturation, with median FeO2 at the start of intubation attempt of 89.5 (IQR 54.5, 91.5) and median SpO2 of 100 (IQR 99, 100). Patients who did not have a desaturation event had a median FeO2 of 90.0 (IQR 88.0, 92.0). CONCLUSIONS Measuring FeO2 during rapid sequence intubation is challenging with feasibility limitations, but may be a more discriminatory metric of adequate preoxygenation.
Collapse
Affiliation(s)
- Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio.
| | - Sara Pierpoint
- University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karen Ahaus
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashish Shah
- Division of Pediatric Emergency Medicine, Rady Children's Hospital, San Diego, California; Department of Pediatrics, University of California - San Diego, San Diego, California
| | - Yin Zhang
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Benjamin Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio
| |
Collapse
|
21
|
Impact of Intubator's Training Level on First-Pass Success of Endotracheal Intubation in Acute Care Settings: A Four-Center Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9070960. [PMID: 35883944 PMCID: PMC9322935 DOI: 10.3390/children9070960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
(1) Background: First-pass success (FPS) of endotracheal intubation is more challenging in children than in adults. We aimed to identify factors associated with FPS of intubation in acute care settings. (2) Methods: We analyzed data of children aged <10 years who underwent intubation within ≤24 h of arrival at four Korean emergency departments (2016−2019). Variables were compared according to FPS. A logistic regression was performed to quantify the association of factors with FPS. An experienced intubator was defined as a senior resident or a specialist. (3) Results: Of 280 children, 169 (60.4%) had FPS. The children with FPS were older (median age, 23.0 vs. 11.0 months; p = 0.018), were less frequently in their infancy (36.1% vs. 50.5%; p = 0.017), and were less likely to have respiratory compromise (41.4% vs. 55.0%; p = 0.030). The children with FPS tended to be more often intubated by experienced intubators than those without FPS (87.0% vs. 78.4%; p = 0.057). Desaturation was rarer in those with FPS. Factors associated with FPS were experienced intubators (aOR, 1.93; 95% CI, 1.01−3.67) and children’s age ≥12 months (1.84; 1.13−3.02). (4) Conclusion: FPS of intubation can be facilitated by deploying or developing clinically competent intubators, particularly for infants, in acute care settings.
Collapse
|
22
|
Pazderka PA, Mastenbrook J, Billian J, Caulfield R, Khan F, Ekblad G, Williams M, Hoyle J. Quality Evaluation of a Checklist for Intubation Preparation in Graduate Medical Education. Cureus 2022; 14:e25830. [PMID: 35836462 PMCID: PMC9273194 DOI: 10.7759/cureus.25830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/05/2022] Open
|
23
|
Pacheco GS, Patanwala AE, Leetch AN, Mendelson JS, Hurst NB, Sakles JC. Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success. Pediatr Emerg Care 2022; 38:e1271-e1276. [PMID: 35482505 DOI: 10.1097/pec.0000000000002592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED. METHODS This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients. RESULTS Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77). CONCLUSIONS In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.
Collapse
Affiliation(s)
| | - Asad E Patanwala
- University of Sydney School of Pharmacy Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | | | | | | | | |
Collapse
|
24
|
Aroonpruksakul N, Sangsungnern P, Kiatchai T. Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial. Transl Pediatr 2022; 11:427-437. [PMID: 35558969 PMCID: PMC9085956 DOI: 10.21037/tp-21-484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction. METHODS This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO2) ≤92%. RESULTS Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO2 was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069). CONCLUSIONS In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII. TRIAL REGISTRATION Thai Clinical Trials Registry TCTR20210802002.
Collapse
Affiliation(s)
- Naiyana Aroonpruksakul
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peerapong Sangsungnern
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Taniga Kiatchai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| |
Collapse
|
25
|
Capone CA, Emerson B, Sweberg T, Polikoff L, Turner DA, Adu‐Darko M, Li S, Glater‐Welt LB, Howell J, Brown CA, Donoghue A, Krawiec C, Shults J, Breuer R, Swain K, Shenoi A, Krishna AS, Al‐Subu A, Harwayne‐Gidansky I, Biagas KV, Kelly SP, Nuthall G, Panisello J, Napolitano N, Giuliano JS, Emeriaud G, Toedt‐Pingel I, Lee A, Page‐Goertz C, Kimura D, Kasagi M, D'Mello J, Parsons SJ, Mallory P, Gima M, Bysani GK, Motomura M, Tarquinio KM, Nett S, Ikeyama T, Shetty R, Sanders RC, Lee JH, Pinto M, Orioles A, Jung P, Shlomovich M, Nadkarni V, Nishisaki A. Intubation practice and outcomes among pediatric emergency departments: A report from National Emergency Airway Registry for Children (NEAR4KIDS). Acad Emerg Med 2022; 29:406-414. [PMID: 34923705 DOI: 10.1111/acem.14431] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/23/2021] [Accepted: 11/22/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Tracheal intubation (TI) practice across pediatric emergency departments (EDs) has not been comprehensively reported. We aim to describe TI practice and outcomes in pediatric EDs in contrast to those in intensive are units (ICUs) and use the data to identify quality improvement targets. METHODS Consecutive TI encounters from pediatric EDs and ICUs in the National Emergency Airway Registry for Children (NEAR4KIDS) database from 2015 to 2018 were analyzed for patient, provider, and practice characteristics and outcomes: adverse TI-associated events (TIAEs), oxygen desaturation (SpO2 < 80%), and procedural success. A multivariable model identified factors associated with TIAEs in the ED. RESULTS A total of 756 TIs in 13 pediatric EDs and 12,512 TIs in 51 pediatric/cardiac ICUs were reported. Median (interquartile range [IQR]) patient age for ED TIs was higher (32 [7-108] months) than that for ICU TIs (15 [3-91] months; p < 0.001). Proportion of TIs for respiratory decompensation (52% of ED vs. 64% ICU), shock (26% vs. 14%), and neurologic deterioration (30% vs. 11%) also differed by location. Limited neck mobility was reported more often in the ED (16% vs. 6%). TIs in the ED were performed more often via video laryngoscopy (64% vs. 29%). Adverse TIAE rates (15.6% ED, 14% ICU; absolute difference = 1.6%, 95% confidence interval [CI] = -1.1 to 4.2; p = 0.23) and severe TIAE rates (5.4% ED, 5.8% ICU; absolute difference = -0.3%, 95% CI = -2.0 to 1.3; p = 0.68) were not different. Oxygen desaturation was less commonly reported in ED TIs (13.6%) than ICU TIs (17%, absolute difference = -3.4%, 95% CI = -5.9 to -0.8; p = 0.016). Among ED TIs, shock as an indication (adjusted odds ratio [aOR] = 2.15, 95% CI = 1.26 to 3.65) and limited mouth opening (aOR = 1.74, 95% CI = 1.04 to 2.93) were independently associated with TIAEs. CONCLUSIONS While TI characteristics vary between pediatric EDs and ICUs, outcomes are similar. Shock and limited mouth opening were independently associated with adverse TI events in the ED.
Collapse
Affiliation(s)
- Christine A. Capone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Beth Emerson
- Department of Pediatrics Yale University School of Medicine New Haven Connecticut USA
| | - Todd Sweberg
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Lee Polikoff
- Division of Critical Care Medicine, Department of Pediatrics The Warren Alpert Medical School of Brown University Providence Rhode Island USA
| | - David A. Turner
- Division of Pediatric Critical Care, Department of Pediatrics Duke Children's Hospital and Health Center Durham North Carolina USA
| | - Michelle Adu‐Darko
- Division of Pediatric Critical Care Medicine Department of Pediatrics University of Virginia Children's Hospital Charlottesville Virginia USA
| | - Simon Li
- Department of Pediatrics Robert Wood Johnson University New Brunswick New Jersey USA
| | - Lily B. Glater‐Welt
- Division of Pediatric Critical Care Medicine, Department of Pediatrics Steven and Alexandra Cohen Children's Medical Center New Hyde Park New York USA
| | - Joy Howell
- Pediatric Critical Care Medicine Department of Pediatrics New York Presbyterian Hospital/Weill Cornell Medical Center New York New York USA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston Massachusetts USA
| | - Aaron Donoghue
- Division of Emergency Medicine Department of Pediatrics Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Conrad Krawiec
- Department of Pediatrics, Pediatric Critical Care Penn State Health Children's Hospital Hershey Pennsylvania USA
| | - Justine Shults
- Division of Biostatistics Department of Biostatistics and Epidemiology University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
| | - Ryan Breuer
- Department of Pediatrics John R. Oishei Children's Hospital Buffalo New York USA
| | - Kelly Swain
- Pediatric and Cardiac Critical Care Duke University Medical Center Durham North Carolina USA
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Ashwin S. Krishna
- Department of Pediatrics and Critical Care Medicine University of Kentucky College of Medicine Kentucky Children's Hospital Lexington Kentucky USA
| | - Awni Al‐Subu
- Division of Pediatric Critical Care Medicine Department of Pediatrics UW Health American Family Children's Hospital University of Wisconsin‐Madison Madison Wisconsin USA
| | - Ilana Harwayne‐Gidansky
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Katherine V. Biagas
- Department of Pediatrics Stony Brook Children's Hospital, Stony Brook University, Renaissance School of Medicine Stony Brook New York USA
| | - Serena P. Kelly
- Department of Pediatrics Oregon Health & Science University Doernbecher Children's Hospital Portland Oregon USA
| | - Gabrielle Nuthall
- Pediatric Critical Care Medicine Starship Children's Hospital Auckland New Zealand
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Natalie Napolitano
- Respiratory Care Department The Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - John S. Giuliano
- Section of Pediatric Critical Care Medicine Department of Pediatrics Yale School of Medicine New Haven Connecticut USA
| | - Guillaume Emeriaud
- Pediatric Critical Care Medicine CHU Sainte Justine Université de Montréal Montreal Quebec Canada
| | - Iris Toedt‐Pingel
- Division of Pediatric Critical Care University of Vermont Children's Hospital Burlington Vermont USA
| | - Anthony Lee
- Division of Critical Care Medicine Nationwide Children's Hospital Ohio State University College of Medicine Columbus Ohio USA
| | | | - Dai Kimura
- Department of Pediatrics University of Tennessee Health Science Center Le Bonheur Children's Hospital Memphis Tennessee USA
| | - Mioko Kasagi
- Pediatric Critical Care & Emergency Medicine Tokyo Metropolitan Children's Medical Center Tokyo Japan
| | - Jenn D'Mello
- Section of Pediatric Emergency Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Simon J. Parsons
- Section of Critical Care Medicine Department of Pediatrics University of Calgary Calgary Alberta Canada
| | - Palen Mallory
- Department of Pediatrics Duke University Durham North Carolina USA
| | - Masafumi Gima
- Critical Care Medicine National Center for Child Health and Development Tokyo Japan
| | | | - Makoto Motomura
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Keiko M. Tarquinio
- Division of Critical Care Medicine Department of Pediatrics Emory University School of Medicine Children's Healthcare of Atlanta Egleston Georgia USA
| | - Sholeen Nett
- Section of Pediatric Critical Care Medicine Children's Hospital at Dartmouth, Dartmouth‐Hitchcock Medical Center Lebanon New Hampshire USA
| | - Takanari Ikeyama
- Division of Pediatric Critical Care Medicine Aichi Children's Health and Medical Center Aichi Japan
| | - Rakshay Shetty
- Department of Pediatrics Rainbow Children's Hospital Bangalore India
| | - Ronald C. Sanders
- Section of Critical Care University of Arkansas for Medical Sciences Little Rock Arkansas USA
| | - Jan Hau Lee
- Children's Intensive Care Unit KK Women's and Children's Hospital Singapore Singapore
| | - Matthew Pinto
- Pediatric Critical Care Medicine Maria Fareri Children's Hospital Valhalla New York USA
| | - Alberto Orioles
- Division of Critical Care Children's Hospitals and Clinics of Minnesota Minneapolis Minnesota USA
| | - Philipp Jung
- Paediatric Department University Hospital Schleswig‐Holstein Campus Lübeck Germany
| | - Mark Shlomovich
- Division of Pediatric Critical Care Medicine Albert Einstein College of Medicine Children's Hospital at Montefiore Bronx New York USA
| | - Vinay Nadkarni
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | - Akira Nishisaki
- Division of Critical Care Medicine Department of Anesthesiology and Critical Care Medicine Children’s Hospital of Philadelphia Philadelphia Pennsylvania USA
| | | |
Collapse
|
26
|
Risk factors for inadequate sedation after endotracheal intubation in the pediatric emergency department. Am J Emerg Med 2022; 56:15-20. [DOI: 10.1016/j.ajem.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/23/2022] [Accepted: 03/04/2022] [Indexed: 11/23/2022] Open
|
27
|
Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative. Ann Emerg Med 2022; 79:333-343. [DOI: 10.1016/j.annemergmed.2021.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/14/2021] [Accepted: 12/21/2021] [Indexed: 12/31/2022]
|
28
|
Shah A, Edmunds K, Dean P, Frey M, Boyd S, Ahaus K, Zhang Y, Varadarajan K, Kerrey BT. Don't Hold Your Breath-A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation. Pediatr Emerg Care 2022; 38:e784-e790. [PMID: 35100777 DOI: 10.1097/pec.0000000000002340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED). DESIGN This was a retrospective, observational study of RSI. SETTING An academic PED. PATIENTS A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019. MEASUREMENT AND MAIN RESULTS Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, -10.5; 95% confidence interval [CI], -17.0 to -4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, -3.5; 95% CI, -8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, -12.5; 95% CI, -17.0 to -4.0). These results did not change when adjusting for age or clustering by provider. CONCLUSIONS We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.
Collapse
Affiliation(s)
| | | | - Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Karen Ahaus
- University of Cincinnati College of Medicine
| | - Yin Zhang
- University of Cincinnati College of Medicine
| | - Kartik Varadarajan
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | | |
Collapse
|
29
|
Elonheimo L, Ljungqvist H, Harve‐Rytsälä H, Jäntti H, Nurmi J. Frequency, indications and success of out-of-hospital intubations in Finnish children. Acta Anaesthesiol Scand 2022; 66:125-131. [PMID: 34514584 DOI: 10.1111/aas.13980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Earlier studies have shown variable results regarding the success of paediatric emergency endotracheal intubation between different settings and operators. We aimed to describe the paediatric population intubated by physician-staffed helicopter emergency medical service (HEMS) and evaluate the factors associated with overall and first-pass success (FPS). METHODS We conducted a retrospective observational cohort study in Finland including all children less than 16 years old who required endotracheal intubation by a HEMS physician from January 2014 to August 2019. Utilising a national HEMS database, we analysed the incidence, indications, overall and first-pass success rates of endotracheal intubation. RESULTS A total of 2731 children were encountered by HEMS, and intubation was attempted in 245 (9%); of these, 22 were younger than 1 year, 103 were aged 1-5 years and 120 were aged 6-15 years. The most common indications for airway management were cardiac arrest for the youngest age group, neurological reasons (e.g., seizures) for those aged 1-5 years and trauma for those aged 6-15. The HEMS physicians had an overall success rate of 100% (95% CI: 98-100) and an FPS rate of 86% (95% CI: 82-90). The FPS rate was lower in the youngest age group (p = .002) and for patients in cardiac arrest (p < .001). CONCLUSIONS Emergency endotracheal intubation of children is successfully performed by a physician staffed HEMS unit even though these procedures are rare. To improve the care, emphasis should be on airway management of infants and patients in cardiac arrest.
Collapse
Affiliation(s)
- Lauri Elonheimo
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
| | | | - Heini Harve‐Rytsälä
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
| | - Helena Jäntti
- Center for Prehospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - Jouni Nurmi
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
- FinnHEMS Research and Development Unit Vantaa Finland
| |
Collapse
|
30
|
Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative. Pediatr Qual Saf 2021; 6:e385. [PMID: 34963998 PMCID: PMC8702256 DOI: 10.1097/pq9.0000000000000385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/18/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative.
Collapse
|
31
|
Strobel AM, Driver BE, Slusher T, Rowland-Fisher A, Reardon RF. Adjunct Devices for the Pediatric Difficult Airway: A Case Report. Ann Emerg Med 2021; 79:348-351. [PMID: 34952727 DOI: 10.1016/j.annemergmed.2021.11.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Indexed: 01/27/2023]
Abstract
This is a case report of a pediatric patient with a difficult airway, in which several airway adjuncts were used simultaneously to successfully provide adequate oxygenation and ventilation during cardiac arrest. Difficult airways are low-incidence, high-risk emergencies in children, and airway adjuncts may be used infrequently, let alone in combination. Included in the discussion of this case are a description of each airway adjunct and a discussion of the process needed to incorporate airway adjuncts safely and effectively into patient care.
Collapse
Affiliation(s)
- Ashley M Strobel
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Minnesota Medical School Masonic Children's Hospital, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN.
| | - Brian E Driver
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Tina Slusher
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Andrea Rowland-Fisher
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| | - Robert F Reardon
- Hennepin Healthcare, Hennepin County Medical Center, Minneapolis, MN; Department of Emergency Medicine, University of Minnesota Medical School, Minneapolis, MN
| |
Collapse
|
32
|
Dean P, Edmunds K, Shah A, Frey M, Zhang Y, Boyd S, Kerrey BT. Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department. Ann Emerg Med 2021; 79:323-332. [PMID: 34952729 DOI: 10.1016/j.annemergmed.2021.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance. METHODS We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model. RESULTS From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90). CONCLUSION We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.
Collapse
Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, San Diego, CA
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yin Zhang
- Division of Emergency Medicine, and the Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
33
|
Abid ES, Miller KA, Monuteaux MC, Nagler J. Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department. Emerg Med J 2021; 39:601-607. [PMID: 34872932 DOI: 10.1136/emermed-2021-211570] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/13/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting. OBJECTIVE We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations. DESIGN AND METHODS We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors. RESULTS During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy. CONCLUSION Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.
Collapse
Affiliation(s)
- Edir S Abid
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
34
|
Kelly GS, Deanehan JK, Dalesio NM. Pediatric Difficult Airway Response Team Utilization in the Emergency Department: A Case Series. Pediatr Emerg Care 2021; 37:e1462-e1467. [PMID: 32195976 DOI: 10.1097/pec.0000000000002073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A multidisciplinary pediatric difficult airway team was created at our institution to respond to hospital-wide airway emergencies. We report the characteristics, indications, and outcomes of these activations that occur in the pediatric emergency department (PED). METHODS Retrospective, single-center cohort study comprised all difficult airway team activations occurring in the PED from the program's inception in 2008 to 2018. Ages of ≤18 years were included. For each case, detailed information was abstracted, including patient factors, PED context and milieu, airway interventions, and airway outcomes. RESULTS There were 15 difficult airway response team activations in the PED during the study period, or 1.4 activations per year. The most common indications for activation were contaminated airways (n = 7; 47%) and history of difficult intubation (n = 4; 27%). Definitive airway management was successful in all cases, except for a single case where intervention was unnecessary. The most commonly performed definitive airway intervention was direct laryngoscopy (n = 6; 40%). There were no instances of emergency front-of-neck access. CONCLUSIONS Difficult airways in the PED were uncommon. Most cases were resolved with familiar equipment including direct laryngoscopy, video laryngoscopy, and supraglottic airways.
Collapse
Affiliation(s)
| | | | - Nicholas M Dalesio
- Anesthesiology and Critical Care Medicine and Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
35
|
Pacheco GS, Patanwala AE, Mendelson JS, Sakles JC. Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period. Pediatr Emerg Care 2021; 37:e1098-e1103. [PMID: 31503130 DOI: 10.1097/pec.0000000000001911] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED. METHODS This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age. RESULTS During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]). CONCLUSIONS In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.
Collapse
Affiliation(s)
- Garrett S Pacheco
- From the Departments of Emergency Medicine and Pediatrics, University of Arizona College of Medicine, Banner University Medical Center Tucson, Tucson, AZ
| | - Asad E Patanwala
- The University of Sydney School of Pharmacy|Royal Prince Alfred Hospital, 1Faculty of Medicine and Health|The University of Sydney|NSW, Sydney, Australia
| | | | - John C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ
| |
Collapse
|
36
|
Kaufmann J, Etspüler A, Wallot P. [Prehospital Resuscitation of Children]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:760-771. [PMID: 34820814 DOI: 10.1055/a-1330-5211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The majority of professionals involved in pre-hospital emergency care do not have explicit paediatric training and have limited experience in the care of life-threatening paediatric emergencies. There is often a fear of being overwhelmed. However, no special paediatric expertise is primarily required to successfully perform resuscitation in children. In addition, the scope of the measures required for successful paediatric resuscitation is on average significantly smaller than for adults. It is essential to know clear and easy-to-implement courses of action, such as those provided by the resuscitation guidelines. For the technical implementation of airway protection, mask-bag ventilation and the laryngeal mask are essential, and for access to the venous system, the intraosseous needle is an aid that overcomes all difficulties almost without exception. With additional support from reference sources, calculation aids and length-related systems, a high level of drug therapy safety can be achieved. In summary, through thorough individual and institutional preparation for paediatric emergencies, safe primary care is feasible by emergency service personnel of any speciality.
Collapse
|
37
|
Brooks JT, Pierce AZ, McCarville P, Sullivan N, Rahimi-Saber A, Payette C, Popova M, Koizumi N, Pourmand A, Yamane D. Video case review for quality improvement during cardiac arrest resuscitation in the emergency department. Int J Clin Pract 2021; 75:e14525. [PMID: 34120384 DOI: 10.1111/ijcp.14525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrests are a leading global cause of mortality. The American Heart Association (AHA) promotes several important strategies associated with improved cardiac arrest (CA) outcomes, including decreasing pulse check time and maintaining a chest compression fraction (CCF) > 0.80. Video review is a potential tool to improve skills and analyse deficiencies in various situations; however, its use in improving medical resuscitation remains poorly studied in the emergency department (ED). We implemented a quality improvement initiative, which utilised video review of CA resuscitations in an effort to improve compliance with such AHA quality metrics. METHODS A cardiopulmonary resuscitation video review team of emergency medicine residents were assembled to analyse CA resuscitations in our urban academic ED. Videos were reviewed by two residents, one of whom was a senior resident (Postgraduate Year 3 or 4), and analysed using Spearman's rank correlation coefficient for numerous quality improvement metrics, including pulse check time, CCF, time to intravenous access and time to patient attached to monitor. RESULTS We collected data on 94 CA resuscitations between July 2017 and June 2020. Average pulse check time was 13.09 (SD ± 5.97) seconds, and 38% of pulse checks were <10 seconds. After the implementation of the video review process, there was a significant decrease in average pulse check time (P = .01) and a significant increase in CCF (P = .01) throughout the study period. CONCLUSIONS Our study suggests that the video review and feedback process was significantly associated with improvements in AHA quality metrics for resuscitation in CA amongst patients presented to the ED.
Collapse
Affiliation(s)
- Joseph T Brooks
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ayal Z Pierce
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Patrick McCarville
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Natalie Sullivan
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Anahita Rahimi-Saber
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Christopher Payette
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Margarita Popova
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Narou Koizumi
- School of Policy and Government, George Mason University, Arlington, VA, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - David Yamane
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| |
Collapse
|
38
|
Leveraging Telemedicine for Quality Improvement Video Review of Critical ICU Events: A Novel Multidisciplinary Form of Education. Crit Care Explor 2021; 3:e0536. [PMID: 34589714 PMCID: PMC8437213 DOI: 10.1097/cce.0000000000000536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The objectives of this study were to codify the events triggering bedside recording and to report the types of performance issues identified that were then used to inform dedicated ICU quality improvement efforts. Design This is a retrospective descriptive analysis of a video review program conducted at a single institution from July 2016 to November 2019. Setting Surgical and Trauma ICU at a single urban academic quaternary care center. Patients All patients admitted to the surgical and trauma ICU between July 2016 and November 2019 were eligible for the study as all ICU beds in our health system institutions are equipped with closed circuit video/audio monitoring. Through an institutional review board approved program, any event triggering the immediate bedside presence of a provider in the ICU is routinely recorded at the discretion of the care team or tele-intensivist. Interventions A database of these events was created over a 3-year period, and cases were reviewed for content, quality improvement, and educational opportunities. Select recordings were analyzed and shared at multidisciplinary/multiprofessional video review sessions. Measurements and Main Results There were 286 critical events video recorded and reviewed in the ICUs between July 2016 and November 2019. The most commonly recorded events included: cardiopulmonary arrests (n = 75), intubations (n = 71), and acute clinical decompensation triggered by nonreassuring vital signs (n = 57) or arrhythmias (n = 13). Of these recordings, 59 were shared at video review conferences, where quality of care was assessed and thematic opportunities for improvement were characterized. Recurrent quality improvement themes that were identified included adherence to protocols, the importance of teamwork and closed-loop communication, clearly designated team leadership, and the use of universal precautions. Conclusions Video review in the ICU is feasible and presents valuable opportunities for quality improvement and educational discussions.
Collapse
|
39
|
Craig SS, Auerbach M, Cheek JA, Babl FE, Oakley E, Nguyen L, Rao A, Dalton S, Lyttle MD, Mintegi S, Nagler J, Mistry RD, Dixon A, Rino P, Kohn Loncarica G, Dalziel SR. Exposure and Confidence With Critical Nonairway Procedures: A Global Survey of Pediatric Emergency Medicine Physicians. Pediatr Emerg Care 2021; 37:e551-e559. [PMID: 32433454 DOI: 10.1097/pec.0000000000002092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age. METHODS Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures. RESULTS Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing. CONCLUSIONS Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.
Collapse
Affiliation(s)
| | | | | | | | | | - Lucia Nguyen
- School of Clinical Sciences at Monash Health, Monash University Melbourne, Australia
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Developing a Profile of Procedural Expertise: A Simulation Study of Tracheal Intubation Using 3-Dimensional Motion Capture. Simul Healthc 2021; 15:251-258. [PMID: 32168289 DOI: 10.1097/sih.0000000000000423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Improving the assessment and training of tracheal intubation is hindered by the lack of a sufficiently validated profile of expertise. Although several studies have examined biomechanics of tracheal intubation, there are significant gaps in the literature. We used 3-dimensional motion capture to study pediatric providers performing simulated tracheal intubation to identify candidate kinematic variables for inclusion in an expert movement profile. METHODS Pediatric anesthesiologists (experienced) and pediatric residents (novices) were recruited from a pediatric institution to perform tracheal intubation on airway mannequins in a motion capture laboratory. Subjects performed 21 trials of tracheal intubation, 3 each of 7 combinations of laryngoscopic visualization (direct or indirect), blade type (straight or curved), and mannequin size (adult or pediatric). We used repeated measures analysis of variance to determine whether various kinematic variables (3-trial average for each participant) were associated with experience. RESULTS Eleven experienced and 15 novice providers performed 567 successful tracheal intubation attempts (9 attempts unsuccessful). For laryngoscopy, experienced providers exhibited shorter path length (total distance traveled by laryngoscope handle; 77.6 ± 26.0 cm versus 113.9 ± 53.7 cm; P = 0.013) and greater angular variability at the left wrist (7.4 degrees versus 5.5 degrees, P = 0.013) and the left elbow (10.1 degrees versus 7.6 degrees, P = 0.03). For intubation, experienced providers exhibited shorter path length of the right hand (mean = 61.1 cm versus 99.9 cm, P < 0.001), lower maximum acceleration of the right hand (0.19 versus 0.14 m/s, P = 0.033), and smaller angular, variability at the right elbow (9.7 degrees versus 7.9 degrees, P = 0.03). CONCLUSIONS Our study and the available literature suggest specific kinematic variables for inclusion in an expert profile for tracheal intubation. Future studies should include a larger sample of practitioners, actual patients, and measures of the cognitive and affective components of expertise.
Collapse
|
41
|
Pediatric Prehospital Advanced Airway Management by Anesthesiologist and Nurse Anesthetist Staffed Critical Care Teams. Prehosp Disaster Med 2021; 36:547-552. [PMID: 34254579 DOI: 10.1017/s1049023x21000637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Prehospital pediatric tracheal intubation (TI) is a possible life-saving intervention that requires adequate experience to mitigate associated complications. The pediatric airway and respiratory physiology present challenges in addition to a relatively rare incidence of prehospital pediatric TI. STUDY OBJECTIVE The aim of this study was to describe characteristics and outcomes of prehospital TI in pediatric patients treated by critical care teams. METHODS This is a sub-group analysis of all pediatric (<16 years old) patients from a prospective, observational, multi-center study on prehospital advanced airway management in the Nordic countries from May 2015 through November 2016. The TIs were performed by anesthesiologists and nurse anesthetists staffing six helicopter and six Rapid Response Car (RRC) prehospital critical care teams. RESULTS In the study, 74 children were tracheal intubated, which corresponds to 3.7% (74/2,027) of the total number of patients. The pediatric patients were intubated by very experienced providers, of which 80% had performed ≥2,500 TIs. The overall TI success rate, first pass success rate, and airway complication rate were in all children (<16 years) 98%, 82%, and 12%. The corresponding rates among infants (<2 years) were 94%, 67%, and 11%. The median time on scene was 30 minutes. CONCLUSION This study observed a high overall prehospital TI success rate in children with relatively few associated complications and short time on scene, despite the challenges presented by the pediatric prehospital TI.
Collapse
|
42
|
Miller KA, Eisenberg MA, Abid ES, Nagler J. Use of the C-MAC Macintosh 0 Blade for Intubation of Infants in the Emergency Department. Pediatr Emerg Care 2021; 37:e404-e405. [PMID: 30422949 DOI: 10.1097/pec.0000000000001665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT First-pass success rates during intubation of infants in the emergency department have been shown to be low. Video laryngoscopy is being increasingly used during advanced airway management in the emergency department, but available data have not supported improved outcomes with use in pediatrics. The newly available Macintosh size 0 (curved) blade for the C-MAC video laryngoscope offers a narrower blade for use in infants. We describe the use of the new C-MAC Macintosh 0 blade for intubation of 2 infants with apnea secondary to respiratory syncytial virus bronchiolitis. The included video recording demonstrates the favorable glottic view and improved maneuverability offered by the narrower blade but also highlights the limitation in use beyond young infants given the short blade length.
Collapse
Affiliation(s)
- Kelsey A Miller
- From the Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | | | | |
Collapse
|
43
|
West JR, O'Keefe BP, Russell JT. Predictors of first pass success without hypoxemia in trauma patients requiring emergent rapid sequence intubation. Trauma Surg Acute Care Open 2021; 6:e000588. [PMID: 34263062 PMCID: PMC8246356 DOI: 10.1136/tsaco-2020-000588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 05/26/2021] [Indexed: 11/10/2022] Open
Abstract
Objective The predictors of first pass success (FPS) without hypoxemia among trauma patients requiring rapid sequence intubation (RSI) in the emergent setting are unknown. Methods Retrospective study of adult trauma patients requiring RSI during a 5-year period comparing the trauma patients achieving FPS without hypoxemia to those who did not. The primary outcome was FPS without hypoxemia evaluated by multivariate logistic regression adjusting for the neuromuscular blocking agent used (succinylcholine or rocuronium), hypoxemia prior to RSI, Glasgow Coma Scale (GCS) scores, the presence of head or facial trauma, and intubating operator level of training. Results 246 patients met our inclusion criteria. The overall FPS rate was 89%, and there was no statistical difference between those receiving either paralytic agent. 167 (69%) patients achieved FPS without hypoxemia. The two groups (those achieving FPS without hypoxemia and those who did not) had similar mean GCS, mean Injury Severity Scores, presence of head or facial trauma, the presence of penetrating trauma, intubating operator-level training, use of direct laryngoscopy, hypoxemia prior to RSI, heart rate per minute, mean systolic blood pressure, and respiratory rate. In the multivariate regression analysis, the use of succinylcholine and GCS score of 13–15 were found to have adjusted ORs of 2.1 (95% CI 1.2 to 3.8) and 2.0 (95% CI 1.0 to 3.3) for FPS without hypoxemia, respectively. Conclusion Trauma patients requiring emergency department RSI with high GCS score and those who received succinylcholine had higher odds of achieving FPS without hypoxemia, a patient safety goal requiring more study. Level of evidence IV. Study type Prognostic.
Collapse
Affiliation(s)
- Jason Randall West
- Emergency Medicine, NYC Health + Hospitals / Lincoln, Bronx, New York, USA
| | - Brandon P O'Keefe
- Emergency Medicine, NYC Health + Hospitals / Lincoln, Bronx, New York, USA.,Emergency Medicine, Maimonides Medical Center, Brooklyn, NY, USA
| | - James T Russell
- Emergency Medicine, NYC Health + Hospitals / Lincoln, Bronx, New York, USA
| |
Collapse
|
44
|
Strobel AM, Alblaihed L. Cardiac Emergencies in Kids. Emerg Med Clin North Am 2021; 39:605-625. [PMID: 34215405 DOI: 10.1016/j.emc.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Encountering a child with congenital heart disease after surgical palliation in the emergency department, specifically the single-ventricle or ventricular assist device, without a basic familiarity of these surgeries can be extremely anxiety provoking. Knowing what common conditions or complications may cause these children to visit the emergency department and how to stabilize will improve the chance for survival and is the premise for this article, regardless of practice setting.
Collapse
Affiliation(s)
- Ashley M Strobel
- Department of Emergency Medicine, University of Minnesota Medical School, Hennepin County Medical Center, University of Minnesota Masonic Children's Hospital, 701 South Park Avenue R2.123, Minneapolis, MN 55414, USA.
| | - Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, University of Maryland Upper Chesapeake Medical System, 500 Upper Chesapeake Drive, Bel Air, MD 21014, USA
| |
Collapse
|
45
|
Wong KU, Gross I, Emerson BL, Goldman MP. Simulated airway drills as a tool to measure and guide improvements in endotracheal intubation preparation in the paediatric emergency department. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2021; 7:561-567. [PMID: 35520983 PMCID: PMC8936761 DOI: 10.1136/bmjstel-2020-000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 11/04/2022]
Abstract
Introduction Emergent paediatric intubation is an infrequent but high-stakes procedure in the paediatric emergency department (PED). Successful intubations depend on efficient and accurate preparation. The aim of this study was to use airway drills (brief in-situ simulations) to identify gaps in our paediatric endotracheal intubation preparation process, to improve on our process and to demonstrate sustainability of these improvements over time in a new staff cohort. Method This was a single-centre, simulation-based improvement study. Baseline simulated airway drills were used to identify barriers in our airway preparation process. Drills were scored for time and accuracy on an iteratively developed 16-item rubric. Interventions were identified and their impact was measured using simulated airway drills. Statistical analysis was performed using unpaired t-tests between the three data collection periods. Results Twenty-five simulated airway drills identified gaps in our airway preparation process and served as our baseline performance. The main problem identified was that staff members had difficulty locating essential airway equipment. Therefore, we optimised and implemented a weight-based airway cart. We demonstrated significant improvement and sustainability in the accuracy of obtaining essential airway equipment from baseline to postintervention (62% vs 74%; p=0.014), and postintervention to sustainability periods (74% vs 77%; p=0.573). Similarly, we decreased and sustained the time (in seconds) required to prepare for a paediatric intubation from baseline to postintervention (173 vs 109; p=0.001) and postintervention to sustainability (109 vs 103; p=0.576). Conclusions Simulated airway drills can be used as a tool to identify process gaps, measure and improve paediatric intubation readiness.
Collapse
Affiliation(s)
- Kei U Wong
- Emergency Medicine (Pediatric Emergency Medicine Division), Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Isabel Gross
- Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Beth L Emerson
- Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael P Goldman
- Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
46
|
Ayanmanesh F, Abdat R, Jurine A, Azale M, Rousseaux G, Coulons S, Samain E, Brasher C, Julien-Marsollier F, Dahmani S. Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children. Anaesth Crit Care Pain Med 2021; 40:100817. [PMID: 33677095 DOI: 10.1016/j.accpm.2021.100817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/13/2020] [Accepted: 10/31/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). METHODS In this prospective observational study, arterial desaturation < 95% SaO2 before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients' age (older or younger than 1 year). RESULTS Complete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01). CONCLUSIONS Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.
Collapse
Affiliation(s)
- Fanny Ayanmanesh
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Rachida Abdat
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Amélie Jurine
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Mehdi Azale
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Guillaume Rousseaux
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Sarah Coulons
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Emmanuel Samain
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Christopher Brasher
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia; Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Florence Julien-Marsollier
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Souhayl Dahmani
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France.
| |
Collapse
|
47
|
Mittiga MR, Frey M, Kerrey BT, Rinderknecht AS, Eckerle MD, Sobolewski B, Johnson LH, Oehler JL, Bennett BL, Chan S, Frey TM, Krummen KM, Lindsay C, Wolfangel K, Richert A, Masur TJ, Bria CL, Hoehn EF, Geis GL. The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:167-171. [PMID: 30883536 DOI: 10.1097/pec.0000000000001742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
ABSTRACT Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.
Collapse
Affiliation(s)
| | - Mary Frey
- From the Division of Emergency Medicine
| | | | | | | | | | | | | | | | | | | | - Kelly M Krummen
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Claire Lindsay
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Kelsey Wolfangel
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Alison Richert
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Tonya J Masur
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | | | | | | |
Collapse
|
48
|
Präklinisches Management von Atemwegs- und Atmungsproblemen im Kindesalter. Notf Rett Med 2021. [DOI: 10.1007/s10049-020-00836-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
49
|
Couto TB, Reis AG, Farhat SCL, Carvalho VEL, Schvartsman C. Changing the view: impact of simulation-based mastery learning in pediatric tracheal intubation with videolaryngoscopy. J Pediatr (Rio J) 2021; 97:30-36. [PMID: 32156536 PMCID: PMC9432116 DOI: 10.1016/j.jped.2019.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/22/2019] [Accepted: 12/26/2019] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To determine the effect of a training program using simulation-based mastery learning on the performance of residents in pediatric intubations with videolaryngoscopy. METHOD Retrospective cohort study carried out in a tertiary pediatric hospital between July 2016 and June 2018 evaluating a database that included the performance of residents before and after training, as well as the outcome of tracheal intubations. A total of 59 pediatric residents were evaluated in the pre-training with a skills' checklist in the scenario with an intubation simulator; subsequently, they were trained individually using a simulator and deliberate practice in the department itself. After training, the residents were expected to have a minimum passing grade (90/100) in a simulated scenario. The success of the first attempted intubation, use of videolaryngoscopy, and complications in patients older than 1year of age during the study period were also recorded in clinical practice. RESULTS Before training, the mean grade was 77.5/100 (SD 15.2), with only 23.7% (14/59) of residents reaching the minimum passing grade of 90/100. After training, 100% of the residents reached the grade, with an average of 94.9/100 (SD 3.2), p<0.01, with only 5.1% (3/59) needing more practice time than that initially allocated. The success rate in the first attempt at intubation in the emergency department with videolaryngoscopy was 77.8% (21/27). The rate of adverse events associated with intubations was 26% (7/27), representing a serious event. CONCLUSIONS Simulation-based mastery learning increased residents' skills related to intubation and allowed safe tracheal intubations with video laryngoscopy.
Collapse
Affiliation(s)
- Thomaz Bittencourt Couto
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil.
| | - Amélia G Reis
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Sylvia C L Farhat
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Vitor E L Carvalho
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
| |
Collapse
|
50
|
Nagler J, Auerbach M, Monuteaux MC, Cheek JA, Babl FE, Oakley E, Nguyen L, Rao A, Dalton S, Lyttle MD, Mintegi S, Mistry RD, Dixon A, Rino P, Kohn-Loncarica G, Dalziel SR, Craig S. Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study. Am J Emerg Med 2020; 42:70-77. [PMID: 33453618 DOI: 10.1016/j.ajem.2020.12.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/22/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. OBJECTIVES Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. METHODS A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. RESULTS 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. CONCLUSION BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.
Collapse
Affiliation(s)
- Joshua Nagler
- Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Pediatric Emergency Care Applied Research Network (PECARN), USA.
| | - Marc Auerbach
- Yale University School of Medicine, New Haven, CT, USA; Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC), USA
| | - Michael C Monuteaux
- Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - John A Cheek
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand
| | - Franz E Babl
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; University of Melbourne, Melbourne, Australia
| | - Ed Oakley
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; University of Melbourne, Melbourne, Australia
| | - Lucia Nguyen
- Peninsula Health, Frankston, Victoria, Australia
| | - Arjun Rao
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Sydney Children's Hospital (Randwick), NSW, Australia; University of New South Wales, Australia; Health Education Training Institute (HETI), New South Wales, Australia
| | - Sarah Dalton
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK; Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK; Paediatric Emergency Research in the United Kingdom & Ireland (PERUKI), UK
| | - Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain; University of the Basque Country, Spain; Research in European Pediatric Emergency Medicine (REPEM), Spain; Red de Investigación de la Sociedad Española de Urgencias de Pediatría/Spanish Pediatric Emergency Research Group (RISeuP/SPERG), Spain
| | - Rakesh D Mistry
- Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC), USA; Children's Hospital Colorado, Aurora, CO, USA
| | - Andrew Dixon
- University of Alberta, Edmonton, Alberta, Canada; Stollery Children's Hospital, Edmonton, Alberta, Canada; Women's and Children's Health Research Institute, Canada; Pediatric Emergency Research Canada (PERC), Canada
| | - Pedro Rino
- Universidad de Buenos Aires, Argentina; Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina; Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Argentina
| | - Guillermo Kohn-Loncarica
- Universidad de Buenos Aires, Argentina; Hospital de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina; Red de Investigación y Desarrollo de la Emergencia Pediátrica Latinoamericana (RIDEPLA), Argentina
| | - Stuart R Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Starship Children's Hospital, Auckland, New Zealand; Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Simon Craig
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Australia and New Zealand; Paediatric Emergency Department, Monash Medical Centre, Melbourne, Australia; Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Australia
| | | |
Collapse
|