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Wilsterman EJ, Nellis ME, Panisello J, Al-Subu A, Breuer R, Kimura D, Krawiec C, Mallory PP, Nett S, Owen E, Parsons SJ, Sanders RC, Garcia-Marcinkiewicz A, Napolitano N, Shults J, Nadkarni VM, Nishisaki A. Evaluating Airway Management in Patients With Trisomy 21 in the PICU and Cardiac ICU: A Retrospective Cohort Study. Pediatr Crit Care Med 2024; 25:335-343. [PMID: 38059735 PMCID: PMC10994735 DOI: 10.1097/pcc.0000000000003418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVES Children with trisomy 21 often have anatomic and physiologic features that may complicate tracheal intubation (TI). TI in critically ill children with trisomy 21 is not well described. We hypothesize that in children with trisomy 21, TI is associated with greater odds of adverse airway outcomes (AAOs), including TI-associated events (TIAEs), and peri-intubation hypoxemia (defined as > 20% decrease in pulse oximetry saturation [Sp o2 ]). DESIGN Retrospective database study using the National Emergency Airway Registry for Children (NEAR4KIDS). SETTING Registry data from 16 North American PICUs and cardiac ICUs (CICUs), from January 2014 to December 2020. PATIENTS A cohort of children under 18 years old who underwent TI in the PICU or CICU from in a NEAR4KIDS center. We identified patients with trisomy 21 and selected matched cohorts within the registry. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We included 8401 TIs in the registry dataset. Children with trisomy 21 accounted for 274 (3.3%) TIs. Among those with trisomy 21, 84% had congenital heart disease and 4% had atlantoaxial instability. Cervical spine protection was used in 6%. The diagnosis of trisomy 21 (vs. without) was associated with lower median weight 7.8 (interquartile range [IQR] 4.5-14.7) kg versus 10.6 (IQR 5.2-25) kg ( p < 0.001), and more higher percentage undergoing TI for oxygenation (46% vs. 32%, p < 0.001) and ventilation failure (41% vs. 35%, p = 0.04). Trisomy 21 patients had more difficult airway features (35% vs. 25%, p = 0.001), including upper airway obstruction (14% vs. 8%, p = 0.001). In addition, a greater percentage of trisomy 21 patients received atropine (34% vs. 26%, p = 0.004); and, lower percentage were intubated with video laryngoscopy (30% vs. 37%, p = 0.023). After 1:10 (trisomy 21:controls) propensity-score matching, we failed to identify an association difference in AAO rates (absolute risk difference -0.6% [95% CI -6.1 to 4.9], p = 0.822). CONCLUSIONS Despite differences in airway risks and TI approaches, we have not identified an association between the diagnosis of trisomy 21 and higher AAOs.
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Affiliation(s)
- Eric J Wilsterman
- Pediatric Critical Care, Department of Pediatrics, New York Presbyterian Weill Cornell Medical Center, New York, NY
| | - Marianne E Nellis
- Pediatric Critical Care, Department of Pediatrics, New York Presbyterian Weill Cornell Medical Center, New York, NY
| | - Josep Panisello
- Critical Care, Department of Pediatrics, Yale Medical School, New Haven, CT
| | - Awni Al-Subu
- Pediatric Critical Care Medicine, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ryan Breuer
- Critical Care Medicine, Department of Pediatrics, Oishei Children's Hospital University at Buffalo, Buffalo, NY
| | - Dai Kimura
- Critical Care Medicine, Department of Pediatrics, Le Bonheur Children's Hospital, Heart Institute, University of Tennessee Health Science Center, Memphis, TN
| | - Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA
| | - Palen P Mallory
- Pediatric Critical Care Medicine, Department of Pediatrics, Duke University, Durham, NC
| | - Sholeen Nett
- Pediatric Critical Care, Department of Pediatrics, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Erin Owen
- Pediatric Critical Care Medicine, Department of Pediatrics, Norton Children's Hospital, University of Louisville, Louisville, KY
| | - Simon J Parsons
- Critical Care, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Annery Garcia-Marcinkiewicz
- General Anesthesiology, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinay M Nadkarni
- Department of Anesthesiology, Critical Care and Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Critical Care, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Coelho LP, Couto TB. Can video laryngoscopy and supplemental oxygen redefine pediatric, infant and neonatal tracheal intubation standards? Transl Pediatr 2024; 13:508-512. [PMID: 38590366 PMCID: PMC10998985 DOI: 10.21037/tp-23-530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/05/2024] [Indexed: 04/10/2024] Open
Affiliation(s)
- Laila Pinto Coelho
- Postgraduate Medical Education Department, University of São Paulo Faculty of Medicine, São Paulo, Brazil
| | - Thomaz Bittencourt Couto
- Pediatric Emergency Department, Instituto da Criança do Hospital das Clínicas, Children’s Hospital, University of São Paulo Faculty of Medicine, São Paulo, Brazil
- Simulation Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
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3
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Stein ML, Sarmiento Argüello LA, Staffa SJ, Heunis J, Egbuta C, Flynn SG, Khan SA, Sabato S, Taicher BM, Chiao F, Bosenberg A, Lee AC, Adams HD, von Ungern-Sternberg BS, Park RS, Peyton JM, Olomu PN, Hunyady AI, Garcia-Marcinkiewicz A, Fiadjoe JE, Kovatsis PG. Airway management in the paediatric difficult intubation registry: a propensity score matched analysis of outcomes over time. EClinicalMedicine 2024; 69:102461. [PMID: 38374968 PMCID: PMC10875248 DOI: 10.1016/j.eclinm.2024.102461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/21/2024] Open
Abstract
Background The Paediatric Difficult Intubation Collaborative identified multiple attempts and persistence with direct laryngoscopy as risk factors for complications in children with difficult tracheal intubations and subsequently engaged in initiatives to reduce repeated attempts and persistence with direct laryngoscopy in children. We hypothesised these efforts would lead to fewer attempts, fewer direct laryngoscopy attempts and decrease complications. Methods Paediatric patients less than 18 years of age with difficult direct laryngoscopy were enrolled in the Paediatric Difficult Intubation Registry. We define patients with difficult direct laryngoscopy as those in whom (1) an attending or consultant obtained a Cormack Lehane Grade 3 or 4 view on direct laryngoscopy, (2) limited mouth opening makes direct laryngoscopy impossible, (3) direct laryngoscopy failed in the preceding 6 months, and (4) direct laryngoscopy was deferred due to perceived risk of harm or poor chance of success. We used a 5:1 propensity score match to compare an early cohort from the initial Paediatric Difficult Intubation Registry analysis (August 6, 2012-January 31, 2015, 785 patients, 13 centres) and a current cohort from the Registry (March 4, 2017-March 31, 2023, 3925 patients, 43 centres). The primary outcome was first attempt success rate between cohorts. Success was defined as confirmed endotracheal intubation and assessed by the treating clinician. Secondary outcomes were eventual success rate, number of attempts at intubation, number of attempts with direct laryngoscopy, the incidence of persistence with direct laryngoscopy, use of supplemental oxygen, all complications, and severe complications. Findings First-attempt success rate was higher in the current cohort (42% vs 32%, OR 1.5 95% CI 1.3-1.8, p < 0.001). In the current cohort, there were fewer attempts (2.2 current vs 2.7 early, regression coefficient -0.5 95% CI -0.6 to -0.4, p < 0.001), fewer attempts with direct laryngoscopy (0.6 current vs 1.0 early, regression coefficient -0.4 95% CI -0.4 to 0.3, p < 0.001), and reduced persistence with direct laryngoscopy beyond two attempts (7.3% current vs 14.1% early, OR 0.5 95% CI 0.4-0.6, p < 0.001). Overall complication rates were similar between cohorts (19% current vs 20% early). Severe complications decreased to 1.8% in the current cohort from 3.2% in the early cohort (OR 0.55 95% CI 0.35-0.87, p = 0.011). Cardiac arrests decreased to 0.8% in the current cohort from 1.8% in the early cohort. We identified persistence with direct laryngoscopy as a potentially modifiable factor associated with severe complications. Interpretation In the current cohort, children with difficult tracheal intubations underwent fewer intubation attempts, fewer attempts with direct laryngoscopy, and had a nearly 50% reduction in severe complications. As persistence with direct laryngoscopy continues to be associated with severe complications, efforts to limit direct laryngoscopy and promote rapid transition to advanced techniques may enhance patient safety. Funding None.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Julia Heunis
- Department of Pediatrics, Boston Children’s Hospital, Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Chinyere Egbuta
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen G. Flynn
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Sabina A. Khan
- Department of Anesthesiology, UTHealth - McGovern Medical School, Houston, TX, USA
| | - Stefano Sabato
- Department of Anaesthesia and Pain Management, Royal Children’s Hospital, and Anaesthesia Research Group, Murdoch Children’s Research Institute, Parkville, Australia
| | - Brad M. Taicher
- Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
| | - Franklin Chiao
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, USA
| | - Adrian Bosenberg
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Angela C. Lee
- Division of Anesthesiology, Pain and Perioperative Medicine, Children’s National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - H. Daniel Adams
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Britta S. von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children’s Hospital, Institute for Paediatric Perioperative Excellence, Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perioperative Medicine Team, Perioperative Care Program, and Telethon Kids Institute, Perth, Australia
| | - Raymond S. Park
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - James M. Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Patrick N. Olomu
- Department of Pediatric Anesthesiology and Pain Management, Children’s Health System of Texas, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Agnes I. Hunyady
- Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Annery Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - John E. Fiadjoe
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Pete G. Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
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Lenz KB, Nishisaki A, Lindell RB, Yehya N, Laverriere EK, Bruins BB, Napolitano N, Traynor DM, Rowan CM, Fitzgerald JC. Peri-Intubation Adverse Events in the Critically Ill Child After Hematopoietic Cell Transplant. Pediatr Crit Care Med 2023; 24:584-593. [PMID: 37098779 PMCID: PMC10330041 DOI: 10.1097/pcc.0000000000003243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
OBJECTIVES Mechanically ventilated children post-hematopoietic cell transplant (HCT) have increased morbidity and mortality compared with other mechanically ventilated critically ill children. Tracheal intubation-associated adverse events (TIAEs) and peri-intubation hypoxemia universally portend worse outcomes. We investigated whether adverse peri-intubation associated events occur at increased frequency in patients with HCT compared with non-HCT oncologic or other PICU patients and therefore might contribute to increased mortality. DESIGN Retrospective cohort between 2014 and 2019. SETTING Single-center academic noncardiac PICU. PATIENTS Critically ill children who underwent tracheal intubation (TI). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data from the local airway management quality improvement databases and Virtual Pediatric Systems were merged. These data were supplemented with a retrospective chart review for HCT-related data, including HCT indication, transplant-related comorbidity status, and patient condition at the time of TI procedure. The primary outcome was defined as the composite of hemodynamic TIAE (hypo/hypertension, arrhythmia, cardiac arrest) and/or peri-intubation hypoxemia (oxygen saturation < 80%) events. One thousand nine hundred thirty-one encounters underwent TI, of which 92 (4.8%) were post-HCT, while 319 (16.5%) had history of malignancy without HCT, and 1,520 (78.7%) had neither HCT nor malignancy. Children post-HCT were older more often had respiratory failure as an indication for intubation, use of catecholamine infusions peri-intubation, and use of noninvasive ventilation prior to intubation. Hemodynamic TIAE or peri-intubation hypoxemia were not different across three groups (HCT 16%, non-HCT with malignancy 10%, other 15). After adjusting for age, difficult airway feature, provider type, device, apneic oxygenation use, and indication for intubation, we did not identify an association between HCT status and the adverse TI outcome (odds ratio, 1.32 for HCT status vs other; 95% CI, 0.72-2.41; p = 0.37). CONCLUSIONS In this single-center study, we did not identify an association between HCT status and hemodynamic TIAE or peri-intubation hypoxemia during TI.
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Affiliation(s)
- Kyle B. Lenz
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Akira Nishisaki
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Robert B. Lindell
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nadir Yehya
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elizabeth K. Laverriere
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of General Anesthesiology, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Benjamin B. Bruins
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Division of General Anesthesiology, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Natalie Napolitano
- Respiratory Therapy Department, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Danielle M. Traynor
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Courtney M. Rowan
- Division of Critical Care Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Julie C. Fitzgerald
- Division of Critical Care, Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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5
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Giuliano J, Krishna A, Napolitano N, Panisello J, Shenoi A, Sanders RC, Rehder K, Al-Subu A, Brown C, Edwards L, Wright L, Pinto M, Harwayne-Gidansky I, Parsons S, Romer A, Laverriere E, Shults J, Yamada NK, Walsh CM, Nadkarni V, Nishisaki A. Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU. Crit Care Med 2023; 51:936-947. [PMID: 37058348 DOI: 10.1097/ccm.0000000000005847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVES To evaluate implementation of a video laryngoscope (VL) as a coaching device to reduce adverse tracheal intubation associated events (TIAEs). DESIGN Prospective multicenter interventional quality improvement study. SETTING Ten PICUs in North America. PATIENTS Patients undergoing tracheal intubation in the PICU. INTERVENTIONS VLs were implemented as coaching devices with standardized coaching language between 2016 and 2020. Laryngoscopists were encouraged to perform direct laryngoscopy with video images only available in real-time for experienced supervising clinician-coaches. MEASUREMENTS AND MAIN RESULTS The primary outcome was TIAEs. Secondary outcomes included severe TIAEs, severe hypoxemia (oxygen saturation < 80%), and first attempt success. Of 5,060 tracheal intubations, a VL was used in 3,580 (71%). VL use increased from baseline (29.7%) to implementation phase (89.4%; p < 0.001). VL use was associated with lower TIAEs (VL 336/3,580 [9.4%] vs standard laryngoscope [SL] 215/1,480 [14.5%]; absolute difference, 5.1%; 95% CI, 3.1-7.2%; p < 0.001). VL use was associated with lower severe TIAE rate (VL 3.9% vs SL 5.3%; p = 0.024), but not associated with a reduction in severe hypoxemia (VL 15.7% vs SL 16.4%; p = 0.58). VL use was associated with higher first attempt success (VL 71.8% vs SL 66.6%; p < 0.001). In the primary analysis after adjusting for site clustering, VL use was associated with lower adverse TIAEs (odds ratio [OR], 0.61; 95% CI, 0.46-0.81; p = 0.001). In secondary analyses, VL use was not significantly associated with severe TIAEs (OR, 0.72; 95% CI, 0.44-1.19; p = 0.20), severe hypoxemia (OR, 0.95; 95% CI, 0.73-1.25; p = 0.734), or first attempt success (OR, 1.28; 95% CI, 0.98-1.67; p = 0.073). After further controlling for patient and provider characteristics, VL use was independently associated with a lower TIAE rate (adjusted OR, 0.65; 95% CI, 0.49-0.86; p = 0.003). CONCLUSIONS Implementation of VL-assisted coaching achieved a high level of adherence across the PICUs. VL use was associated with reduced adverse TIAEs.
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Affiliation(s)
- John Giuliano
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT
| | - Ashwin Krishna
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Natalie Napolitano
- Respiratory Therapy Department, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Josep Panisello
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Asha Shenoi
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Kyle Rehder
- Division of Pediatric Critical Care, Duke Children's Hospital, Durham, NC
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, UW Health American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Calvin Brown
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Lauren Edwards
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Lisa Wright
- Department of Pediatrics and Critical Care Medicine, University of Kentucky College of Medicine, Kentucky Children's Hospital, Lexington, KY
| | - Matthew Pinto
- Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital, Valhalla, NY
| | - Ilana Harwayne-Gidansky
- Department of Pediatrics, Bernard and Millie Duker Children's Hospital at Albany Medical Center, Albany, NY
| | - Simon Parsons
- Division of Critical Care, Alberta Children's Hospital, Calgary, AB, Canada
| | - Amy Romer
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Laverriere
- Division of Critical Care Medicine and Division of General Anesthesiology at Children's Hospital of Philadelphia, Philadelphia, PA
| | - Justine Shults
- Division of Biostatistics, Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nicole K Yamada
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, The Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, ON, Canada
| | - Vinay Nadkarni
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Senthil K, Daly Guris RJ, Vutskits L, Lockman JL. The law of unintended consequences: the crutch of video laryngoscopy. THE LANCET. RESPIRATORY MEDICINE 2023:S2213-2600(23)00228-X. [PMID: 37385283 DOI: 10.1016/s2213-2600(23)00228-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Kumaran Senthil
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 19104 USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104 USA; Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104 USA.
| | - Rodrigo J Daly Guris
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 19104 USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104 USA; Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104 USA
| | - Laszlo Vutskits
- Department of Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Justin L Lockman
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, 19104 USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104 USA; Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104 USA
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Shukla A, Shanker R, Singh VK, Singh GP, Srivastava T. Non-channeled Video Laryngoscopy as an Alternative to Conventional Laryngoscopy for Intubating Adult Patients in the Intensive Care Unit. Cureus 2023; 15:e40716. [PMID: 37485208 PMCID: PMC10359833 DOI: 10.7759/cureus.40716] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2023] [Indexed: 07/25/2023] Open
Abstract
Background Endotracheal intubation in the intensive care unit (ICU) is often a risky procedure due to the emergency situation, unstable condition of the patient, and technical problems such as inadequate positioning. Several new techniques, such as video laryngoscopy, have been developed recently to improve the success rate of first-pass intubations and reduce complications. We conducted this study to compare a non-channeled reusable video laryngoscope BPL VL-02 (manufactured by BPL Medical Technologies, Bangalore, India) with a conventional laryngoscope for intubation of adult patients in the ICU. Methodology A total of 72 ICU patients were randomly allocated to be intubated with either conventional direct laryngoscopy via Macintosh blade (group A) or video laryngoscopy with BPL VL-02 (group B). All patients were intubated by the primary investigator and the assistant noted the following parameters: the total number of intubation attempts, total duration of intubation, assistance or alternative technique required, Cormack Lehane grading, and any complications. Results There was no significant difference in the Cormack Lehane grading, number of attempts, or complications between the two groups. On comparing the assistance required during intubation in patients, it was observed that four (11.11%) patients in group A and seven (19.44%) patients in group B needed backward, upward, and rightward pressure on the larynx assistance during intubation. In five (13.89%) patients in group B, Stylet was required during intubation. The difference was statistically significant (p = 0.0308). The video laryngoscopy group (group B) had a longer mean duration of intubation (64.36 ± 6.28 seconds) compared to group A (45.72 ± 11.45 seconds), and the difference was statistically significant (p < 0.0001). Conclusions Non-channeled video laryngoscope (BPL VL-02) is not a suitable alternative to conventional direct laryngoscopy with a Macintosh blade in terms of successful first-pass intubation, total duration of intubation, and assistance required.
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Affiliation(s)
- Aparna Shukla
- Anaesthesiology, King George's Medical University, Lucknow, IND
| | - Ravi Shanker
- Anaesthesiology, King George's Medical University, Lucknow, IND
| | - Vipin K Singh
- Anaesthesiology, King George's Medical University, Lucknow, IND
| | | | - Tanushree Srivastava
- Anaesthesiology, Integral Institute of Medical Sciences and Research, Lucknow, IND
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8
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Butragueño-Laiseca L, Torres L, O’Campo E, de la Mata Navazo S, Toledano J, López-Herce J, Mencía S. Evaluación de las intubaciones endotraqueales en una unidad de cuidados intensivos pediátricos. An Pediatr (Barc) 2023. [DOI: 10.1016/j.anpedi.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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9
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Butragueño-Laiseca L, Torres L, O'Campo E, de la Mata Navazo S, Toledano J, López-Herce J, Mencía S. Evaluation of tracheal intubations in a paediatric intensive care unit. An Pediatr (Barc) 2023; 98:109-118. [PMID: 36740510 DOI: 10.1016/j.anpede.2023.01.005] [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: 05/20/2022] [Accepted: 09/29/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Tracheal intubation is a frequent procedure in paediatric intensive care units (PICUs) that carries a risk of complications that can increase morbidity and mortality. PATIENTS AND METHODS Prospective, longitudinal, observational study in patients intubated in a level III PICU between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events. RESULTS The analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5% vs 56.3%; P = .759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P = .028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including 1 case of cardiac arrest, 2 cases of severe hypotension and 1 of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P < .002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events. CONCLUSIONS In critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events.
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Affiliation(s)
- Laura Butragueño-Laiseca
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañon, Madrid, Spain.
| | - Laura Torres
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Elena O'Campo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Sara de la Mata Navazo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), Madrid, Spain
| | - Javier Toledano
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Jesús López-Herce
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón, Redes de Investigación Cooperativa Orientadas a Resultados en Salud (RICORS), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Santiago Mencía
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañon, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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10
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The Association of Teamwork and Adverse Tracheal Intubation–Associated Events in Advanced Airway Management in the PICU. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1756715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
AbstractTracheal intubation (TI) in critically ill children is a life-saving but high-risk procedure that involves multiple team members with diverse clinical skills. We aim to examine the association between the provider-reported teamwork rating and the occurrence of adverse TI-associated events (TIAEs). A retrospective analysis of prospectively collected data from 45 pediatric intensive care units in the National Emergency Airway Registry for Children (NEAR4KIDS) database from January 2013 to March 2018 was performed. A composite teamwork score was generated using the average of each of five (7-point Likert scale) domains in the teamwork assessment tool. Poor teamwork was defined as an average score of 4 or lower. Team provider stress data were also recorded with each intubation. A total of 12,536 TIs were reported from 2013 to 2018. Approximately 4.1% (n = 520) rated a poor teamwork score. TIs indicated for shock were more commonly associated with a poor teamwork score, while those indicated for procedures and those utilizing neuromuscular blockade were less commonly associated with a poor teamwork score. TIs with poor teamwork were associated with a higher occurrence of adverse TIAE (24.4% vs 14.4%, p < 0.001), severe TIAE (13.7% vs 5.9%, p < 0.001), and peri-intubation hypoxemia < 80% (26.4% vs 17.9%, p < 0.001). After adjusting for indication, provider type, and neuromuscular blockade use, poor teamwork was associated with higher odds of adverse TIAEs (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.35–2.34), severe TIAEs (OR, 2.23; 95% CI, 1.47–3.37), and hypoxemia (OR, 1.63; 95% CI, 1.25–2.03). TIs with poor teamwork were independently associated with a higher occurrence of TIAEs, severe TIAEs, and hypoxemia.
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11
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Endlich Y, Hore PJ, Baker PA, Beckmann LA, Bradley WP, Chan KLE, Chapman GA, Jephcott CGA, Kruger PS, Newton A, Roessler P. Updated guideline on equipment to manage difficult airways: Australian and New Zealand College of Anaesthetists. Anaesth Intensive Care 2022; 50:430-446. [PMID: 35722809 DOI: 10.1177/0310057x221082664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The Australian and New Zealand College of Anaesthetists (ANZCA) recently reviewed and updated the guideline on equipment to manage a difficult airway. An ANZCA-established document development group, which included representatives from the Australasian College for Emergency Medicine and the College of Intensive Care Medicine of Australia and New Zealand, performed the review, which is based on expert consensus, an extensive literature review, and bi-nationwide consultation. The guideline (PG56(A) 2021, https://www.anzca.edu.au/getattachment/02fe1a4c-14f0-4ad1-8337-c281d26bfa17/PS56-Guideline-on-equipment-to-manage-difficult-airways) is accompanied by a detailed background paper (PG56(A)BP 2021, https://www.anzca.edu.au/getattachment/9ef4cd97-2f02-47fe-a63a-9f74fa7c68ac/PG56(A)BP-Guideline-on-equipment-to-manage-difficult-airways-Background-Paper), from which the current recommendations are reproduced on behalf of, and with the permission of, ANZCA. The updated 2021 guideline replaces the 2012 version and aims to provide an updated, objective, informed, transparent, and evidence-based review of equipment to manage difficult airways.
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Affiliation(s)
- Yasmin Endlich
- Department of Anaesthesia and Acute Pain Medicine, Royal Adelaide Hospital, Adelaide, Australia.,Department of Paediatric Anaesthesia, Women's and Children's Hospital, North Adelaide, Australia.,Faculty of Anaesthesia, University of Adelaide, Adelaide, Australia
| | - Phillipa J Hore
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Paul A Baker
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.,Department of Anaesthesia, Starship Children's Hospital, Auckland, New Zealand
| | - Linda A Beckmann
- Department of Anaesthesia and Acute Pain Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - William P Bradley
- Department of Anaesthesia and Perioperative Medicine, The Alfred, Melbourne, Australia.,Faculty of Anaesthesia, Monash University, Melbourne, Australia
| | - Kah L E Chan
- Department of Anaesthesia and Acute Pain Medicine, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Gordon A Chapman
- Department of Anaesthesia, Royal Perth Hospital, Perth, Australia.,Faculty of Anaesthesia, University of Western Australia, Perth, Australia
| | | | - Peter S Kruger
- Department of Intensive Care Medicine, Princess Alexandra Hospital, Brisbane, Australia
| | - Alastair Newton
- Department of Emergency Medicine, The Prince Charles Hospital, Brisbane, Australia.,Retrieval Services Queensland, Brisbane, Australia
| | - Peter Roessler
- Safety and Advocacy Unit, Australian and New Zealand College of Anaesthetists, Melbourne, Australia
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12
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Thompson A, Irving SY, Hales R, Quinn R, Chittams J, Himebauch A, Nishisaki A. Simulation-Facilitated Education for Pediatric Critical Care Nurse Practitioners' Airway Management Skills: A 10-Year Experience. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1745832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractThis study aimed to describe the process of the development and implementation with report of our 10-year experience with a simulation-facilitated airway management curriculum for pediatric acute care nurse practitioners in a large academic pediatric intensive care unit. This is a retrospective observational study. The study was conducted at a single-center quaternary noncardiac pediatric intensive care unit in an urban children's hospital in the United States. A pediatric critical care airway management curriculum for nurse practitioners consisting 4 hours of combined didactic and simulation-facilitated education followed by hands-on experience in the operating room. Tracheal intubations performed by nurse practitioners in the pediatric intensive care unit were tracked by a local quality improvement database, NEAR4KIDS from January 2009 to December 2018. Since curriculum initiation, 39 nurse practitioners completed the program. Nurse practitioners functioned as the first provider to attempt intubation in 473 of 3,128 intubations (15%). Also, 309 of 473 (65%) were successful at first attempt. Implementation of a simulation-facilitated pediatric airway management curriculum successfully supported the ongoing airway management participation and first attempt intubation success by nurse practitioners in the pediatric intensive care unit over the 10-year period.
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Affiliation(s)
- Allison Thompson
- Division of Critical Care Medicine, Nemours Children's Hospital, Delaware, Wilmington, Delaware, United States
| | - Sharon Y. Irving
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
- Division of Critical Care Medicine, Department of Nursing and Clinical Care Services, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Roberta Hales
- Center for Simulation, Advanced Education and Innovation, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Ryan Quinn
- Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
| | - Jesse Chittams
- Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States
| | - Adam Himebauch
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Akira Nishisaki
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States
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13
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Davis KF, Rosenblatt S, Buffman H, Polikoff L, Napolitano N, Giuliano JS, Sanders RC, Edwards LR, Krishna AS, Parsons SJ, Al-Subu A, Krawiec C, Harwayne-Gidansky I, Vanderford P, Salfity N, Lane-Fall M, Nadkarni V, Nishisaki A. Facilitators and Barriers to Implementing Two Quality Improvement Interventions Across 10 Pediatric Intensive Care Units: Video Laryngoscopy-Assisted Coaching and Apneic Oxygenation. Am J Med Qual 2022; 37:255-265. [PMID: 34935683 DOI: 10.1097/jmq.0000000000000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To better understand facilitators and barriers to implementation of quality improvement (QI) efforts, this study examined 2 evidence-based interventions, video laryngoscopy (VL)-assisted coaching, and apneic oxygenation (AO). One focus group with frontline clinicians was held at each of the 10 participating pediatric intensive care units. Qualitative analysis identified common and unique themes. Intervention fidelity was monitored with a priori defined success as >50% VL-assisted coaching or >80% AO use for 3 consecutive months. Eighty percent of intensive care units with VL-assisted coaching and 20% with AO met this criteria during the study period. Common facilitator themes were adequate device accessibility, having a QI culture, and strong leadership. Common barrier themes included poor device accessibility and perception of delay in care. A consistently identified theme in the successful sites was strong QI leadership, while unsuccessful sites consistently identified insufficient education. These facilitators and barriers should be proactively addressed during dissemination of these interventions.
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Affiliation(s)
- Katherine Finn Davis
- School of Nursing and Dental Hygiene, University of Hawai'i at Mānoa, Honolulu, HI
| | - Samuel Rosenblatt
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hayley Buffman
- Center for Simulation, Advanced Education and Innovation, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lee Polikoff
- Division of Pediatric Critical Care Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - John S Giuliano
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Lauren R Edwards
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Ashwin S Krishna
- Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KT
| | - Simon J Parsons
- Department of Pediatrics, Section of Critical Care Medicine, Alberta Children's Hospital, Calgary, AB, Canada
| | - Awni Al-Subu
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Conrad Krawiec
- Division of Pediatrics Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, PA
| | | | - Paula Vanderford
- Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Portland, OR
| | - Nina Salfity
- Division of Critical Care, Phoenix Children's Hospital, Phoenix, AZ
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Simulation, Advanced Education and Innovation, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Simulation, Advanced Education and Innovation, The Children's Hospital of Philadelphia, Philadelphia, PA
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14
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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: 3] [Impact Index Per Article: 1.5] [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.
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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
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15
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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]
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16
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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [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: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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17
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V Salis-Soglio N, Hummler H, Schwarz S, Mendler MR. Success rate and duration of orotracheal intubation of premature infants by healthcare providers with different levels of experience using a video laryngoscope as compared to direct laryngoscopy in a simulation-based setting. Front Pediatr 2022; 10:1031847. [PMID: 36507131 PMCID: PMC9731376 DOI: 10.3389/fped.2022.1031847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/07/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Endotracheal intubation of very low birth weight infants (VLBWI) is an essential procedure in NICUs, but intubation experience is often limited. Video laryngoscopy (VL) has been described as a tool to improve intubation skills, but studies in high-risk neonatal populations are limited. OBJECTIVE The aim of this study was to investigate whether VL is a useful tool to support airway management in high-risk premature infants with inexperienced operators. METHODS In this crossover study predominantly inexperienced participants were exposed in random sequence to VL and conventional direct laryngoscopy (DL) for endotracheal intubation of a VLBWI simulation manikin to measure total time, number of attempts, success rate on first attempt, view of the vocal cords and perceived subjective safety until successful intubation. RESULTS In our study group of 94 participants there was no significant difference in the total time (mean VL: 34 s (±24 s); DL: 37 s (±28 s), p = 0.246), while the number of intubation attempts using VL was significantly lower (mean VL: 1.22 (±0.53); DL: 1.37 (±0.60), p = 0.023). Success rate of VL during the first attempt was significantly higher (VL: 84%; DL 69%, p = 0.016), view of the vocal cords was significantly better and perceived subjective safety was increased using VL. CONCLUSIONS Our study results suggest that with rather inexperienced operators, VL can be a useful tool to increase rate of successful endotracheal intubation of VLBWI and to improve their perceived safety during the procedure, which may have an impact on mortality and/or morbidity.
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Affiliation(s)
| | - Helmut Hummler
- Divison of Neonatology, Department of Pediatrics, University of Ulm, Ulm, Germany.,Divison of Neonatology, Department of Pediatrics, University of Tübingen, Tübingen, Germany
| | - Stephan Schwarz
- Divison of Neonatology, Department of Pediatrics, University of Ulm, Ulm, Germany
| | - Marc R Mendler
- Divison of Neonatology, Department of Pediatrics, University of Ulm, Ulm, Germany
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18
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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.
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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
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [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] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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20
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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21
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Nishisaki A, Lee A, Li S, Sanders RC, Brown CA, Rehder KJ, Napolitano N, Montgomery VL, Adu-Darko M, Bysani GK, Harwayne-Gidansky I, Howell JD, Nett S, Orioles A, Pinto M, Shenoi A, Tellez D, Kelly SP, Register M, Tarquinio K, Simon D, Krawiec C, Shults J, Nadkarni V. Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators. Crit Care Med 2021; 49:250-260. [PMID: 33177363 DOI: 10.1097/ccm.0000000000004725] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the effect of a tracheal intubation safety bundle on adverse tracheal intubation-associated events across 15 PICUs. DESIGN Multicenter time-series study. SETTING PICUs in the United States. PATIENTS All patients received tracheal intubations in ICUs. INTERVENTIONS We implemented a tracheal intubation safety bundle as a quality-improvement intervention that includes: 1) quarterly site benchmark performance report and 2) airway safety checklists (preprocedure risk factor, approach, and role planning, preprocedure bedside "time-out," and immediate postprocedure debriefing). We define each quality-improvement phase as baseline (-24 to -12 mo before checklist implementation), benchmark performance reporting only (-12 to 0 mo before checklist implementation), implementation (checklist implementation start to time achieving > 80% bundle adherence), early bundle adherence (0-12 mo), and sustained (late) bundle adherence (12-24 mo). Bundle adherence was defined a priori as greater than 80% of checklist use for tracheal intubations for 3 consecutive months. MEASUREMENTS AND MAIN RESULTS The primary outcome was the adverse tracheal intubation-associated event, and secondary outcomes included severe tracheal intubation-associated events, multiple tracheal intubation attempts, and hypoxemia less than 80%.From January 2013 to December 2015, out of 19 participating PICUs, 15 ICUs (79%) achieved bundle adherence. Among the 15 ICUs, the adverse tracheal intubation-associated event rates were baseline phase: 217/1,241 (17.5%), benchmark reporting only phase: 257/1,750 (14.7%), early 0-12 month complete bundle compliance phase: 247/1,591 (15.5%), and late 12-24 month complete bundle compliance phase: 137/1,002 (13.7%). After adjusting for patient characteristics and clustering by site, the adverse tracheal intubation-associated event rate significantly decreased compared with baseline: benchmark: odds ratio, 0.83 (0.72-0.97; p = 0.016); early bundle: odds ratio, 0.80 (0.63-1.02; p = 0.074); and late bundle odds ratio, 0.63 (0.47-0.83; p = 0.001). CONCLUSIONS Effective implementation of a quality-improvement bundle was associated with a decrease in the adverse tracheal intubation-associated event that was sustained for 24 months.
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Affiliation(s)
- Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anthony Lee
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, OH
| | - Simon Li
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Maria Fareri Children's Hospital, Valhalla, NY
| | - Ronald C Sanders
- Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kyle J Rehder
- Division of Pediatric Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Vicki L Montgomery
- Division of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY
| | - Michelle Adu-Darko
- Division of Critical Care, Children's Hospital of the University of Virginia, Charlottesville, VA
| | - G Kris Bysani
- Pediatric Critical Care Medicine, Pediatric Acute Care Associates of North Texas PLLC, Medical City Children's Hospital, Dallas, TX
| | | | - Joy D Howell
- Department of Pediatrics, New York-Presbyterian Weill Cornell Medical Center, New York, NY
| | - Sholeen Nett
- Division of Pediatric Critical Care, Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Alberto Orioles
- Division of Critical Care, Children's Hospital and Clinics of Minnesota, Minneapolis, MN
| | - Matthew Pinto
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Maria Fareri Children's Hospital, Valhalla, NY
| | - Asha Shenoi
- Department of Pediatrics, Division of Pediatric Critical Care, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KY
| | - David Tellez
- Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ
| | - Serena P Kelly
- Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Portland, OR
| | - Melinda Register
- Department of Respiratory Therapy, Children's Healthcare of Atlanta, Atlanta, GA
| | - Keiko Tarquinio
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta GA
| | - Dennis Simon
- Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Conrad Krawiec
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA
| | - Justine Shults
- Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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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.
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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
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23
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Peterson JD, Puricelli MD, Alkhateeb A, Figueroa AD, Fletcher SL, Smith RJH, Kacmarynski DSF. Rigid Video Laryngoscopy for Intubation in Severe Pierre Robin Sequence: A Retrospective Review. Laryngoscope 2020; 131:1647-1651. [PMID: 33300625 DOI: 10.1002/lary.29262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/15/2020] [Accepted: 10/30/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS The anatomy of children with severe Pierre Robin sequence can present a challenge for direct laryngoscopy and intubation. Advanced techniques including flexible fiberoptic laryngoscopic intubation have been described but require highly specialized skill and equipment. Rigid video laryngoscopy is more accessible but has not been described in this population. STUDY DESIGN Retrospective cohort study. METHODS A retrospective review was completed at a tertiary care center of all children between January 2016 and March 2020 with Pierre Robin sequence who underwent a mandibular distraction osteogenesis procedure. Intubation events were collected, and a descriptive analysis was performed. A univariate logistic regression model was applied to direct laryngoscopy and flexible fiberoptic laryngoscopy with rigid video laryngoscopy as a reference. RESULTS Twenty-five patients were identified with a total of 56 endotracheal events. All patients were successfully intubated. Direct laryngoscopy was successful at first intubation attempt in 47.3% (9/19) of events. Six direct laryngoscopy events required switching to another device. Rigid video laryngoscopy was successful at first intubation attempt in 80.5% (29/36) of events. Two cases required switching to another device. Flexible fiberoptic laryngoscopy was found successful at first intubation attempt in 88.9% (8/9) of events. Direct laryngoscopy was 4 times more likely to fail first intubation attempt when compared to rigid video laryngoscopy (P < .05). There was no significant difference between rigid video laryngoscopy and flexible fiberoptic laryngoscopy for intubation. CONCLUSIONS For children with Pierre Robin sequence rigid video laryngoscopy should be considered as a first attempt intubation device both in the operating room and for emergent situations. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1647-1651, 2021.
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Affiliation(s)
- Joseph D Peterson
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Michael D Puricelli
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Ahmed Alkhateeb
- Department of Otolaryngology, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Aaron D Figueroa
- Department of Oral and Maxillofacial Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Steven L Fletcher
- Department of Oral and Maxillofacial Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Richard J H Smith
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
| | - Deborah S F Kacmarynski
- Department of Otolaryngology-Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, U.S.A
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The New Trainee Effect in Tracheal Intubation Procedural Safety Across PICUs in North America: A Report From National Emergency Airway Registry for Children. Pediatr Crit Care Med 2020; 21:1042-1050. [PMID: 32740182 DOI: 10.1097/pcc.0000000000002480] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Tracheal intubation carries a high risk of adverse events. The current literature is unclear regarding the "New Trainee Effect" on tracheal intubation safety in the PICU. We evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation associated events. We hypothesize 1) PICUs with pediatric critical care medicine fellowship programs have more adverse tracheal intubation associated events during the first quarter (July-September) of the academic year compared with the rest of the year and 2) tracheal intubation associated event rates and first attempt success performed by pediatric critical care medicine fellows improve through the 3-year clinical fellowship. DESIGN Retrospective cohort study. SETTING Thirty-seven North American PICUs participating in National Emergency Airway Registry for Children. PATIENTS All patients who underwent tracheal intubations in the PICU from July 2013 to June 2017. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The occurrence of any tracheal intubation associated events during the first quarter of the academic year (July-September) was compared with the rest in four different types of PICUs: PICUs with fellows and residents, PICUs with fellows only, PICUs with residents only, and PICUs without trainees. For the second hypothesis, tracheal intubations by critical care medicine fellows were categorized by training level and quarter for 3 years of fellowship (i.e., July-September of 1st yr pediatric critical care medicine fellowship = first quarter, October-December of 1st yr pediatric critical care medicine fellowship = second quarter, and April-June during 3rd year = 12th quarter). A total of 9,774 tracheal intubations were reported. Seven-thousand forty-seven tracheal intubations (72%) were from PICUs with fellows and residents, 525 (5%) with fellows only, 1,201 (12%) with residents only, and 1,001 (10%) with no trainees. There was no difference in the occurrence of tracheal intubation associated events in the first quarter versus the rest of the year (all PICUs: July-September 14.9% vs October-June 15.2%; p = 0.76). There was no difference between these two periods in each type of PICUs (all p ≥ 0.19). For tracheal intubations by critical care medicine fellows (n = 3,836), tracheal intubation associated events significantly decreased over the fellowship: second quarter odds ratio 0.64 (95% CI, 0.45-0.91), third quarter odds ratio 0.58 (95% CI, 0.42-0.82), and 12th quarter odds ratio 0.40 (95% CI, 0.24-0.67) using the first quarter as reference after adjusting for patient and device characteristics. First attempt success significantly improved during fellowship: second quarter odds ratio 1.39 (95% CI, 1.04-1.85), third quarter odds ratio 1.59 (95% CI, 1.20-2.09), and 12th quarter odds ratio 2.11 (95% CI, 1.42-3.14). CONCLUSIONS The New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.
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Direct laryngoscopy assisted fiberoptic intubation: A novel technique for the pediatric airway. Int J Pediatr Otorhinolaryngol 2020; 137:110232. [PMID: 32896347 DOI: 10.1016/j.ijporl.2020.110232] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 06/24/2020] [Accepted: 06/24/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To introduce a novel intubation technique for difficult pediatric airways. METHODS This two-provider technique requires a direct laryngoscope and a flexible fiberoptic laryngoscope. One provider performs direct laryngoscopy which allows for introduction of the flexible laryngoscope. The second provider inserts the flexible laryngoscope with the endotracheal tube loaded, through the oropharynx in to the subglottis. RESULTS We report three pediatric patients that were initially unable to be intubated by conventional methods. We were ultimately able to successfully intubate these patients with difficult airways using our novel technique. CONCLUSIONS We found that this technique of direct laryngoscopy assisted flexible fiberoptic intubation is a useful adjunct in select pediatric difficult airway patients.
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Rivera-Tocancipá D. Pediatric airway: What is new in approaches and treatments? COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2020. [DOI: 10.5554/22562087.e945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Perioperative morbidity and mortality are high among patients in the extremes of life undergoing anesthesia. Complications in children occur mainly as a result of airway management-related events such as difficult approach, laryngospasm, bronchospasm and severe hypoxemia, which may result in cardiac arrest, neurological deficit or death. Reports and new considerations that have changed clinical practice in pediatric airway management have emerged in recent years. This narrative literature review seeks to summarize and detail the findings on the primary cause of morbidity and mortality in pediatric anesthesia and to highlight those things that anesthetists need to be aware of, according to the scientific reports that have been changing practice in pediatric anesthesia.
This review focuses on the identification of “new” and specific practices that have emerged over the past 10 years and have helped reduce complications associated with pediatric airway management. At least 9 practices grouped into 4 groups are described: assessment, approach techniques, devices, and algorithms. The same devices used in adults are essentially all available for the management of the pediatric airway, and anesthesia-related morbidity and mortality can be reduced through improved quality of care in pediatrics.
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Couto TB, Reis AG, Farhat SCL, Carvalho VEDL, Schvartsman C. Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department. Medicine (Baltimore) 2020; 99:e22289. [PMID: 32957386 PMCID: PMC7505323 DOI: 10.1097/md.0000000000022289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to compare the success of first-attempt tracheal intubation in pediatric patients >1-year old performed using video versus direct laryngoscopy and compare the frequency of tracheal intubation-associated events and desaturation among these patients.Prospective observational cohort study conducted in an Academic pediatric tertiary emergency department. We compared 50 children intubated with Mcgrath Mac video laryngoscope (VL group) and an historical series of 141 children intubated with direct laryngoscopy (DL group). All patients were aged 1 to 18 years.The first attempt success rates were 68% (34/50) and 37.6% (53/141) in the VL and DL groups (P < .01), respectively. There was a lower proportion of tracheal intubation-associated events in the VL group (VL, 31.3% [15/50] vs DL, 67.8% [97/141]; P < .01) and no significant differences in desaturation (VL, 35% [14/50] vs DL 51.8% [72/141]; P = .06). The median number of attempts was 1 (range, 1-5) for the VL group and 2 (range, 1-8) for the DL group (P < .01). Multivariate logistic regression showed that video laryngoscope use was associated with higher chances of first-attempt intubation with an odds ratio of 4.5 (95% confidence interval, 1.9-10.4, P < 0.01).Compared with direct laryngoscopy, VL was associated with higher success rates of first-attempt tracheal intubations and lower rates of tracheal intubation-associated events.
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Fiadjoe J, Nishisaki A. Normal and difficult airways in children: "What's New"-Current evidence. Paediatr Anaesth 2020; 30:257-263. [PMID: 31869488 PMCID: PMC8613833 DOI: 10.1111/pan.13798] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 12/17/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Pediatric difficult airway is one of the most challenging clinical situations. We will review new concepts and evidence in pediatric normal and difficult airway management in the operating room, intensive care unit, Emergency Department, and neonatal intensive care unit. METHODS Expert review of the recent literature. RESULTS Cognitive factors, teamwork, and communication play a major role in managing pediatric difficult airway. Earlier studies evaluated videolaryngoscopes in a monolithic way yielding inconclusive results regarding their effectiveness. There are, however, substantial differences among videolaryngoscopes particularly angulated vs. nonangulated blades which have different learning and use characteristics. Each airway device has strengths and weaknesses, and combining these devices to leverage both strengths will likely yield success. In the pediatric intensive care unit, emergency department and neonatal intensive care units, adverse tracheal intubation-associated events and hypoxemia are commonly reported. Specific patient, clinician, and practice factors are associated with these occurrences. In both the operating room and other clinical areas, use of passive oxygenation will provide additional laryngoscopy time. The use of neuromuscular blockade was thought to be contraindicated in difficult airway patients. Newer evidence from observational studies showed that controlled ventilation with or without neuromuscular blockade is associated with fewer adverse events in the operating room. Similarly, a multicenter neonatal intensive care unit study showed fewer adverse events in infants who received neuromuscular blockade. Neuromuscular blockade should be avoided in patients with mucopolysaccharidosis, head and neck radiation, airway masses, and external airway compression for anticipated worsening airway collapse with neuromuscular blocker administration. CONCLUSION Clinicians caring for children with difficult airways should consider new cognitive paradigms and concepts, leverage the strengths of multiple devices, and consider the role of alternate anesthetic approaches such as controlled ventilation and use of neuromuscular blocking drugs in select situations. Anesthesiologists can partner with intensive care and emergency department and neonatology clinicians to improve the safety of airway management in all clinical settings.
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Affiliation(s)
- John Fiadjoe
- Attending physician, Anesthesiology, The Children’s Hospital of Philadelphia, Associate Professor of Anesthesiology & Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine
| | - Akira Nishisaki
- Attending physician, Critical Care Medicine, Co-Medical Director, Center for Simulation, Advanced Education, and Innovation at The Children’s Hospital of Philadelphia, Associate Professor, Anesthesiology, Critical Care Medicine, and Pediatrics, University of Pennsylvania Perelman School of Medicine
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Zhou M, Xi X, Li M, Wang S, Liu Z, Liu JQ. Video Laryngoscopy Improves the Success of Neonatal Tracheal Intubation for Novices but Not for Experienced Medical Staff. Front Pediatr 2020; 8:445. [PMID: 32850555 PMCID: PMC7423830 DOI: 10.3389/fped.2020.00445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background: There is limited evidence on the use of video laryngoscopy (VL) in neonatal tracheal intubation (NTI) during neonatal resuscitation. In this study, we aimed to compare the difference between direct laryngoscopy (DL) and VL in NTI of trainees during neonatal resuscitation training. Materials and Methods: A prospective observational study was conducted during a neonatal resuscitation training course to examine three circumstances: NTI by experienced medical staff (EMS) and less-experienced medical staff (LEMS) in a neonatal resuscitation scenario; NTI by EMS and LEMS with an ongoing chest compression; and NTI by midwives who were novices in the procedure. The trainees were given scenarios or were shown demonstrations on newborn simulation manikins and were required to perform an NTI on a simulation manikin using DL and/or VL. The mean intubation time and success rate of intubation were measured. Results: The mean NTI time for EMS using VL (24.1 ± 7.2 s) was significantly longer than that using DL intubation (18.1 ± 6.9 s, P < 0.001), whereas there was no significant difference between using VL and DL for LEMS. EMS spent slightly less time on NTI than did LEMS using both VL and DL, but there were no statistically significant differences (both p > 0.05). The NTI success rate for EMS using VL (48.0%, 12/25) was significantly lower than that using DL (88.0%, 22/25, P = 0.004), while the NTI success rate for LEMS using VL (68.2%, 15/22 vs. 40.9%, 9/22) was higher than that using DL, but there was no statistical significance. When NTI was required with ongoing chest compressions, there was no significant difference in the mean NTI time and success rate between using VL and DL for EMS or LEMS. In the group of midwives who were novices in NTI, after they watched a demonstration teaching NTI, the intubation time using VL (19.6 ± 9.0 s) was significantly shorter than that using DL (28.0 ± 6.7 s, P < 0.001). The success rate of NTI using VL was significantly higher (96.2%; 25/26) than that using DL (69.2%; 18/26). Conclusion: The video laryngoscopy could be an effective training tool for inexperienced staff in developing the skill of tracheal intubation.
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Affiliation(s)
- Ming Zhou
- Department of Neonatology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaohong Xi
- Department of Neonatology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Min Li
- Department of Neonatology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Silu Wang
- Department of Neonatology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhiqiang Liu
- Department of Anesthesiology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiang-Qin Liu
- Department of Neonatology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
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Desai N, Johnson M, Priddis K, Ray S, Chigaru L. Comparative evaluation of Airtraq™ and GlideScope® videolaryngoscopes for difficult pediatric intubation in a Pierre Robin manikin. Eur J Pediatr 2019; 178:1105-1111. [PMID: 31119438 DOI: 10.1007/s00431-019-03396-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 11/25/2022]
Abstract
Airway management in children is associated with anatomical and physiological challenges compared with adults. Pierre Robin sequence (PRS) is a condition characterized by micrognathia, glossoptosis, and cleft palate and related to a difficult airway. Both the Airtraq™ and GlideScope® have never been previously directly compared in PRS. Our aim was to evaluate the performance of these two airway devices in a PRS manikin for ethical and practical reasons. Between April and July 2017, 26, pediatric intensive care clinical fellows or trainees from a tertiary pediatric center were recruited to participate. In this prospective and randomized crossover trial, all participants first set up the Airtraq™ and the GlideScope® and then used these videolaryngoscopes to intubate an AirSim® PRS manikin. Our primary outcome measure was the duration of the successful intubation attempt. Duration of the successful intubation attempt was 18.1 (14.2-34.9 [10.2-51.3]) s for the Airtraq™ compared to 31.1 (18.7-55.6 [6.2-119]) s for the GlideScope® (p = 0.045). Setup time was 50.0 ± 6.9 s for the Airtraq™ and 27.8 ± 8.6 s for the GlideScope® (p < 0.001).Conclusion: Even though setup time was longer, the characteristics of intubation performance were superior with the Airtraq™ relative to the GlideScope® in an AirSim® PRS manikin. What is Known: • Several case reports have described the successful use of Airtraq™ to intubate children with Pierre Robin sequence. • The GlideScope® has demonstrated similar rates of first-attempt successful intubation to flexible fiberoptic bronchoscopy in a Pierre Robin sequence manikin. What is New: • In the hands of pediatric non-airway specialists, the characteristics of intubation performance, including the duration of the successful intubation attempt, are superior with the Airtraq™ compared with the GlideScope® in a Pierre Robin sequence manikin. • Setup time for the Airtraq™ is, however, longer relative to that for the GlideScope®.
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Affiliation(s)
- Neel Desai
- Department of Anaesthetics, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK.
| | - Mae Johnson
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
- Department of Anaesthetics, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK
| | - Kat Priddis
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
| | - Samiran Ray
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
- Respiratory, Critical Care and Anaesthesia Section, University College London Great Ormond Street Institute of Child Health, 30 Guildford Street, London, UK
| | - Linda Chigaru
- Children's Acute Transport Service, Ormond House, 26-27 Boswell Street, London, UK
- Department of Anaesthetics, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, UK
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Sinha R, Kumar KR, Kalaiyarasan RK, Khanna P, Ray BR, Pandey RK, Punj J, Darlong V. Evaluation of performance of C-MAC ® video laryngoscope Miller blade size zero for endotracheal intubation in preterm and ex-preterm infants: A retrospective analysis. Indian J Anaesth 2019; 63:284-288. [PMID: 31000892 PMCID: PMC6460968 DOI: 10.4103/ija.ija_753_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: The preterm and ex-preterm babies form a separate group among the paediatric population with unique airway anatomy. The utility of C-MAC® Video laryngoscope (VL) for routine intubation of preterm babies has not been evaluated. The purpose of this study is to report the performance of C-MAC® VL Miller blade size-0 for endotracheal intubation in preterm babies at our institute. Methods: After Institute Ethics Committee approval, a retrospective study was designed to evaluate the performance of C-MAC® VL for intubation in preterm and ex-preterm babies. The medical files, and video recordings of preterm babies up to 60 weeks of post-gestational age who had undergone surgery for retinopathy of prematurity from January 2014 to April 2016 were reviewed. All babies were intubated with C-MAC® Miller blade size-0. Demographic parameters, time to best glottic view (TTGV), time to intubate (TTI), ease and number of intubation attempts were assessed. Episodes of desaturation and complications related to intubation were recorded. Results: Data of 37 preterm and ex-preterm babies were analysed. The mean age and weight at the time of surgery were 40.5 (±4.9) weeks and 2532 (±879) grams respectively. The median TTGV and TTI were 11.0 and 22.0 seconds. A total of 32 babies (86.5%) were intubated on initial attempt and five were intubated on second attempt. Stylet was used to facilitate intubation in all infants. There was no incidence of desaturation, mucosal injury or bleeding. Conclusion: C-MAC video laryngoscope Miller blade size 0 is suitable for endotracheal intubation in preterm and ex-preterm infants.
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Affiliation(s)
- Renu Sinha
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Kanil Ranjith Kumar
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ram Kumar Kalaiyarasan
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Puneet Khanna
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Bikash Ranjan Ray
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ravinder Kumar Pandey
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Jyotsna Punj
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Vanlal Darlong
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Pouppirt NR, Nassar R, Napolitano N, Nawab U, Nishisaki A, Nadkarni V, Ades A, Foglia EE. Association Between Video Laryngoscopy and Adverse Tracheal Intubation-Associated Events in the Neonatal Intensive Care Unit. J Pediatr 2018; 201:281-284.e1. [PMID: 29980290 PMCID: PMC6288797 DOI: 10.1016/j.jpeds.2018.05.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 04/23/2018] [Accepted: 05/30/2018] [Indexed: 11/19/2022]
Abstract
The effect of video laryngoscopy on adverse events during neonatal tracheal intubation is unknown. In this single site retrospective cohort study, video laryngoscopy was independently associated with decreased risk for adverse events during neonatal intubation.
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Affiliation(s)
- Nicole R Pouppirt
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Rula Nassar
- Division of Neonatology, Christiana Care Health System, Wilmington, DE
| | - Natalie Napolitano
- Respiratory Therapy Department, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ursula Nawab
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Anne Ades
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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[Systematic analysis of airway registries in emergency medicine]. Anaesthesist 2018; 67:664-673. [PMID: 30105516 DOI: 10.1007/s00101-018-0476-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 07/07/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications. METHODS A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care. RESULTS A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%. CONCLUSION This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.
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Abstract
This article reviews the definition, pathophysiology, etiology, assessment, and management of acute respiratory failure in children. Acute respiratory failure is the inability of the respiratory system to maintain oxygenation or eliminate carbon dioxide. Acute respiratory failure is a common cause for admission to a pediatric intensive care unit. Most causes of acute respiratory failure can be grouped into one of three categories: lung parenchymal disease, airway obstruction, or neuromuscular dysfunction. Many patients with acute respiratory failure are managed successfully with noninvasive respiratory support; however, in severe cases, patients may require intubation and mechanical ventilation. [Pediatr Ann. 2018;47(7):e268-e273.].
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Abstract
OBJECTIVES As of July 2013, pediatric resident trainee guidelines in the United States no longer require proficiency in nonneonatal tracheal intubation. We hypothesized that laryngoscopy by pediatric residents has decreased over time, with a more pronounced decrease after this guideline change. DESIGN Prospective cohort study. SETTING Twenty-five PICUs at various children's hospitals across the United States. PATIENTS Tracheal intubations performed in PICUs from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children). INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Prospective cohort study in which all primary tracheal intubations occurring in the United States from July 2010 to June 2016 in the multicenter tracheal intubation database (National Emergency Airway Registry for Children) were analyzed. Participating PICU leaders were also asked to describe their local airway management training for residents. Resident participation trends over time, stratified by presence of a Pediatric Critical Care Medicine fellowship and airway training curriculum for residents, were described. A total of 9,203 tracheal intubations from 25 PICUs were reported. Pediatric residents participated in 16% of tracheal intubations as first laryngoscopists: 14% in PICUs with a Pediatric Critical Care Medicine fellowship and 34% in PICUs without one (p < 0.001). Resident participation decreased significantly over time (3.4% per year; p < 0.001). The decrease was significant in ICUs with a Pediatric Critical Care Medicine fellowship (p < 0.001) but not in ICUs without one (p = 0.73). After adjusting for site-level clustering, patient characteristics, and Pediatric Critical Care Medicine fellowship presence, the Accreditation Council for Graduate Medical Education guideline change was not associated with lower participation by residents (odds ratio, 0.86; 95% CI, 0.59-1.24; p = 0.43). The downward trend of resident participation was similar regardless of the presence of an airway curriculum for residents. CONCLUSION Laryngoscopy by pediatric residents has substantially decreased over time. This downward trend was not associated with the 2013 Accreditation Council for Graduate Medical Education change in residency requirements.
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Frequency of Desaturation and Association With Hemodynamic Adverse Events During Tracheal Intubations in PICUs. Pediatr Crit Care Med 2018; 19:e41-e50. [PMID: 29210925 DOI: 10.1097/pcc.0000000000001384] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation-associated events. DESIGN Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network's quality improvement project from January 2012 to December 2014. SETTING International PICUs. PATIENTS Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs. INTERVENTIONS tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation-associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia. MEASUREMENTS AND MAIN RESULTS A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation-associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation-associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 1.83 (95% CI, 1.34-2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation-associated events: adjusted odds ratio 2.16 (95% CI, 1.54-3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations (p < 0.001). CONCLUSIONS In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.
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Park R, Peyton J, Fiadjoe J, Hunyady A, Kimball T, Zurakowski D, Kovatsis P. The efficacy of GlideScope® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. Br J Anaesth 2017; 119:984-992. [DOI: 10.1093/bja/aex344] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2017] [Indexed: 12/24/2022] Open
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Tracheal Intubation: Developing a View on Video Laryngoscopy. Pediatr Crit Care Med 2017; 18:801-803. [PMID: 28796704 DOI: 10.1097/pcc.0000000000001210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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