The impact of postintubation chest radiograph during pediatric and neonatal critical care transport

New Formula for Nasal Endotracheal Intubation in Extremely Low-Birth Weight Infants in the Emergency Transport Setting: The "Genoa Formula"

OBJECTIVE

The purpose of this study was to find a predictive equation for estimating the optimal nasal endotracheal tube insertion depth in extremely low-birth weight infants (ELBWs) requiring invasive ventilation in the critical care interfacility transport setting.

METHODS

We retrospectively calculated the optimal tube insertion depth in a cohort of neonates ≤ 1,000 g born at our neonatal intensive care unit and nasally intubated within the first 24 hours of life from January 2019 to May 2020.

RESULTS

A total of 75 ELBW infants were included, with a median gestational age of 26.6 weeks (range, 22.1-32.6 weeks) and a median birth weight of 780 g (range, 410-990 g). The linear regression of the estimated optimal endotracheal tube insertion depth showed a good correlation when plotted against weight (R² = 0.491); thus, a new weight-based formula was obtained.

CONCLUSION

The proposed weight-based formula (the "Genoa formula") may help in predicting optimal insertion depths for nasal intubation in ELBW neonates, especially when a prompt radiologic confirmation of the tube position is not available, as during neonatal critical care transport.

Dealing with the Sick Rural Surgery Patient in Need of Transfer

Care for rural and urban surgical patients is increasingly more complex due to advancing knowledge and technology. Interhospital transfers occur in approximately 10% of index encounters at rural hospitals secondary to mismatch of patient needs and local resources. Due to the recent expansion of air transport to rural areas, distance and geography are less of a barrier. The interhospital transfer process is understudied and far from standardized. Interhospital transfer status is associated with increase in mortality, complications, length of stay, and costs. The cost, price to patients, and safety of air ambulance transports cannot be ignored.

Development of a novel reference nomogram for endotracheal intubation in neonatal emergency transport setting

AIM

Neonatal endotracheal intubation is a challenging procedure during transport. The aim of this study was to evaluate the effectiveness of the emergency intubation guidelines followed by our Neonatal Emergency Transport Service (NETS).

METHODS

Our transport intubation guidelines follows a weight-based nomogram for nasal intubation, and the tube position is clinically verified after intubation, while the postintubation chest X-ray is postponed to Neonatal Intensive Care Unit (NICU) admission. Data on postnatal age, weight and tube insertion depth were obtained from the online NETS clinical database, and the postintubation chest X-ray images were assessed.

RESULTS

During the study period, 161 newborn infants were nasally intubated during transport, and received a postintubation radiograph at NICU admission. A total of 130 neonates (80.7%) had the endotracheal tube (ETT) correctly positioned between T1 and T2 vertebrae, while 12 (7.5%) was at C7 vertebrae level and 19 (11.8%) at T3. No patients had ETT tip positioned at T4 vertebrae level or below. No adverse events related to intubation were observed.

CONCLUSION

Our intubation procedure showed a good reliability and safety in neonatal critical care transport, although chest X-ray to confirm the tube placement is postponed to NICU arrival. Based on our results, we suggest a revised version of weight-based nomogram for nasal intubation.

Prediction of the midtracheal level based on external anatomical landmarks: implication of the optimal insertion depth of endotracheal tubes in pediatric patients

BACKGROUND

Optimal positioning of endotracheal tubes (ETTs) decreases the risk of accidental extubation or endobronchial intubation. This study evaluated the usefulness of external anatomical landmarks as practical references for determining an insertion depth of an ETT in pediatric patients.

METHODS

Computed tomography images of the necks of 183 pediatric patients (≤16 years of age) were reviewed. Levels corresponding to the vocal cords, cricoid cartilage, suprasternal notch, manubriosternal junction, and carina were identified on sagittal reconstructed images. The surface measurements from the cricoid cartilage to the suprasternal notch and that from the suprasternal notch to the manubriosternal junction were determined. Bland-Altman analysis was used to interpret the relationship between the midtracheal level and the surface measurements.

RESULTS

The difference between the midtracheal level and the surface distance from the cricoid cartilage to the suprasternal notch was 3.5 ± 7.0 mm, which was closer to zero than that between the midtracheal level and the surface distance from the suprasternal notch to the manubriosternal junction of 15.1 ± 6.1 mm.

CONCLUSION

The midtracheal level, helpful in planning the insertion depth of an ETT, can be predicted by measuring the surface distance from the cricoid cartilage to suprasternal notch in pediatric patients.

Complications during intrahospital transport of critically ill patients: Focus on risk identification and prevention

Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies.