1
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Dean P, Geis G, Hoehn EF, Lautz AJ, Edmunds K, Shah A, Zhang Y, Frey M, Boyd S, Nagler J, Miller KA, Neubrand TL, Cabrera N, Kopp TM, Wadih E, Kannikeswaran N, VanDeWall A, Hewett Brumberg EK, Donoghue A, Palladino L, O'Connell KJ, Mazzawi M, Tam DCF, Murray M, Kerrey B. High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence. Resuscitation 2023; 190:109875. [PMID: 37327848 DOI: 10.1016/j.resuscitation.2023.109875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.
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Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Gary Geis
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Erin F Hoehn
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Division of Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - Andrew J Lautz
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Joshua Nagler
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Kelsey A Miller
- Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Tara L Neubrand
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States.
| | - Natasha Cabrera
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Tara M Kopp
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Esper Wadih
- Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States.
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Audrey VanDeWall
- Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States.
| | - Elizabeth K Hewett Brumberg
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.
| | - Aaron Donoghue
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Lauren Palladino
- Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
| | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Malek Mazzawi
- Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Derek Chi Fung Tam
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Matthew Murray
- Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States.
| | - Benjamin Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States.
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2
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Rodriguez-Nunez A. Emergent pediatric intubation: Not a simple or safe procedure. Then, prepare to avoid failure! Resuscitation 2023; 190:109905. [PMID: 37453690 DOI: 10.1016/j.resuscitation.2023.109905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Antonio Rodriguez-Nunez
- Pediatric Critical, Intermediate and Palliative Care Section, University Hospital of Santiago de Compostela, Santiago de Compostela, Spain; SICRUS Research Group, Santiago de Compostela Research Intitute, Santiago de Compostela, Spain; CLINURSID Research Group, University of Santiago de Compostela, Santiago de Compostela, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS), RD21/0012/0025, Instituto de Salud Carlos III, Madrid, Spain.
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3
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VanDeWall A, Harris-Kober S, Farooqi A, Kannikeswaran N. Peri-Intubation Arrest in High Risk vs. Standard Risk Pediatric Trauma Patients Undergoing Endotracheal Intubation. Am J Emerg Med 2023; 67:79-83. [PMID: 36806979 DOI: 10.1016/j.ajem.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND While the anatomically difficult airway has been studied in pediatric trauma patients, physiologic risk factors are poorly understood. Our objective was to evaluate if previously published high risk physiologic criteria for difficult airway in medical patients is associated with adverse outcomes in pediatric trauma patients. METHODS This was a retrospective chart review of patients ≤18 years with traumatic injuries who underwent endotracheal intubation (EI) in a pediatric emergency department (PED) between 2016 and 2021. High risk criteria evaluated included 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation. Our primary outcome was peri-intubation cardiac arrest, defined as cardiac arrest within 10 minutes of EI. Secondary outcomes included in-hospital cardiac arrest and mortality and first pass EI success. RESULTS One third (n = 32; 36.4%) of the 88 patients analyzed had at least one high risk criteria. When compared to the standard risk group, those in the high risk group had a higher incidence of peri-intubation arrest (28.1% vs. 0%, difference: 28.1%, 95% CI: 10.1-46.2), PED/in-hospital arrest (43.8% vs. 3.4%, difference: 38.4%, 95% CI: 17.8-59.0) and in-hospital mortality (33.4% vs. 3.6%, difference: 29.8%, 95% CI: 8.4-46.9). Having multiple high risk criteria progressively increased the odds of post-intubation PED/in-hospital cardiac arrest (1 risk factor: OR = 6.7, 95% CI: 1.5-30.2; 2 risk factors: OR = 12.5, 95% CI: 2.3-70.0; ≥ 3 risk factors: OR = 56.1, 95% CI: 6.0-523.8). CONCLUSIONS The presence of high risk physiologic criteria is associated with increased incidence of peri-intubation, in-hospital arrest, and death in pediatric trauma patients. Children with multiple risk factors are at an incremental risk of cardiac arrest.
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Affiliation(s)
- Audrey VanDeWall
- Pediatric Emergency Medicine Fellow, Division of Emergency Medicine, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, United States of America.
| | - Sarah Harris-Kober
- Pediatric Resident, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, United States of America.
| | - Ahmad Farooqi
- Research Assistant (Biostatistician), Department of Pediatrics, Central Michigan University, Detroit, MI 48201, United States of America
| | - Nirupama Kannikeswaran
- Professor of Pediatrics & Emergency Medicine, Central Michigan University, Division of Emergency Medicine, Children's Hospital of Michigan, 3901, Beaubien Blvd, Detroit, MI 48201, United States of America.
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4
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Winters ME, Hu K, Martinez JP, Mallemat H, Brady WJ. The critical care literature 2021. Am J Emerg Med 2023; 63:12-21. [PMID: 36306647 DOI: 10.1016/j.ajem.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/01/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
An emergency physician (EP) is often the first provider to evaluate, resuscitate, and manage a critically ill patient. Over the past two decades, the annual hours of critical care delivered in emergency departments across the United States has dramatically increased. During the period from 2006 to 2014, the extent of critical care provided in the emergency department (ED) to critically ill patients increased approximately 80%. During the same time period, the number of intubated patients cared for in the ED increased by approximately 16%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. Prolonged ED boarding times for critically ill patients is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality. As a result, it is imperative for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine, so that the critically ill ED patient care receive current evidence-based care. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, cardiogenic shock, transfusions, and sepsis.
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Affiliation(s)
- Michael E Winters
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Kami Hu
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Joseph P Martinez
- Departments of Emergency Medicine and Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Haney Mallemat
- Internal Medicine and Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - William J Brady
- Departments of Emergency Medicine and Medicine, University of Virginia School of Medicine, Charlottesville, VA 22908, USA
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5
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Loomba RS, Patel R, Kunnel E, Villarreal EG, Farias JS, Flores S. Peri-Intubation Cardiorespiratory Arrest Risk in Pediatric Patients: A Systematic Review. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1758477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
AbstractEndotracheal intubation is associated with an increased risk of cardiorespiratory arrest. Various factors modulate the risk of peri-intubation cardiorespiratory arrest. The primary objective of this study was to determine the risk of peri-intubation cardiorespiratory arrest in pediatric patients in a hospital setting, and the secondary objective was to determine the effect of various factors on the peri-intubation cardiorespiratory arrest risk. A systematic review was performed to identify eligible manuscripts. Studies were deemed appropriate if they included pediatric patients in a hospital setting not exclusively intubated for an indication of cardiorespiratory arrest. Data were extracted from studies deemed eligible for inclusion. A pooled risk of cardiorespiratory arrest was determined. A Bayesian linear regression was conducted to model the risk of cardiorespiratory arrest. All data used in this were study-level data. A total of 11 studies with 14,424 intubations were included in the final analyses. The setting for six (54.5%) studies was the emergency department. The baseline adjusted risk for peri-intubation cardiorespiratory arrest in pediatric patients was 3.78%. The mean coefficient for a respiratory indication for intubation was −0.06, indicating that a respiratory indication for intubation reduced the per-intubation cardiorespiratory arrest risk by 0.06%. The mean coefficient for use of ketamine was 0.07, the mean coefficient for use of a benzodiazepine was −0.14, the mean coefficient for use of a vagolytic was −0.01, and the mean coefficient for use of neuromuscular blockade was −0.40. Pediatric patients during the peri-intubation period have the risk of developing cardiorespiratory arrest. The pooled findings demonstrate associations that seem to highlight the importance of maintaining adequate systemic oxygen delivery to limit this risk.
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Affiliation(s)
- Rohit S. Loomba
- Division of Pediatric Cardiac Critical Care, Advocate Children's Hospital, Oak Lawn, Illinois, United States
- Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, Illinois, United States
| | - Riddhi Patel
- Division of Pediatric Cardiac Critical Care, Advocate Children's Hospital, Oak Lawn, Illinois, United States
| | - Elizabeth Kunnel
- Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Chicago, Illinois, United States
| | - Enrique G. Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Juan S. Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Saul Flores
- Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas, United States
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States
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6
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Butler K, Winters M. The Physiologically Difficult Intubation. Emerg Med Clin North Am 2022; 40:615-627. [DOI: 10.1016/j.emc.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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7
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Kornegay JG, Daya MR. Emergency Department Cardiac Arrests: Who, When, and Why? Insights from Sweden. Resuscitation 2022; 175:44-45. [DOI: 10.1016/j.resuscitation.2022.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/12/2022] [Indexed: 11/28/2022]
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8
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Gil-Jardiné C, Jabre P, Adnet F, Nicol T, Ecollan P, Guihard B, Ferdynus C, Bocquet V, Combes X. Incidence and factors associated with out-of-hospital peri-intubation cardiac arrest: a secondary analysis of the CURASMUR trial. Intern Emerg Med 2022; 17:611-617. [PMID: 35037125 DOI: 10.1007/s11739-021-02903-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/27/2021] [Indexed: 11/25/2022]
Abstract
The Incidence of peri-intubation cardiac arrest (PICA) has been rarely assessed in the out-of-hospital setting. The objectives of this study were to assess the incidence and factors associated with PICA (cardiac arrest occurring within 15 min of intubation) in an out-of-hospital emergency setting, wherein emergency physicians perform standardized airway management using a rapid sequence intubation technique in adult patients. This was a secondary analysis of the "Succinylcholine versus Rocuronium for out-of-hospital emergency intubation" (CURASMUR) trial, which compared the first attempt intubation success rate between succinylcholine and rocuronium in adult patients requiring emergency tracheal intubation for any vital distress except cardiac arrest. Enrollment occurred from January 2014 to August 2016 in 17 French out-of-hospital emergency medical units. All operators were emergency physicians. The PICA incidence was recorded and multivariable logistic regression analysis was used to identify the factors associated with its occurrence. A total of 1226 patients were included with a mean age of 55.9 ± 19 years. PICA was recorded in 35 (2.8%) patients. Multivariable analysis indicated that the occurrence of PICA was independently associated with a body mass index (BMI) > 30 kg m2 [adjusted odds ratio (aOR) 4.85; 95% confidence interval (CI) 1.82-12.90, p = 0.02], oxygen saturation (SpO2) before intubation < 90% (aOR 3.4; 95% CI 1.50-7.60, p = 0.003), difficult intubation (defined by an Intubation Difficulty Score [IDS] > 5, [aOR 3.59; 95% CI 1.82-8.08, p = 0.02], the use of rocuronium instead of succinylcholine (aOR 2.47; 95% CI 1.08-5.64, p = 0.03), post intubation hypoxaemia (aOR 2.70; 95% CI 1.05-6.95, p = 0.04), post-intubation hypotension (aOR 4.07; 95% CI 1.62-10.22, p = 0.003), and pulmonary aspiration(aOR 4.78; 95% CI 1.48-15.36, p = 0.009). Early PICA occurred in approximately 3% of cases in the out-of-hospital setting. We identified several independent risk factors for PICA, including obesity, hypoxaemia before intubation and difficult intubation.
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Affiliation(s)
- Cédric Gil-Jardiné
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France
| | - Patricia Jabre
- AP-HP, Service d'Aide Médicale d'Urgence (SAMU) de Paris and Paris Sudden Death Expertise Center, Université Paris Descartes, Paris, France
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Frederic Adnet
- Urgences-SAMU 93, Unite Recherche-Enseignement-Qualite, Hopital Avicenne, Bobigny, France
| | - Thomas Nicol
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Patrick Ecollan
- Department of Anesthesia and Critical Care-SAMU, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Université Paris Descartes, 149 rue de Sèvres, 75015, Paris, France
| | - Bertrand Guihard
- Department of Emergency, CHU de la Réunion, Université de La Réunion, Réunion, France
| | - Cyril Ferdynus
- INSERM CIC 1410 Clinical and Epidemiology/CHU Réunion/Université de la Réunion, Saint-Pierre, Reunion, France
| | - Valery Bocquet
- Departement d'Informatique Clinique, Centre Hospitalier Universitaire de La Réunion Site Félix Guyon, Saint-Denis, France
| | - Xavier Combes
- Department of Emergency, CHU de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux cedex, France.
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Sustained Improvement in the Performance of Rapid Sequence Intubation Five Years after a Quality Improvement Initiative. Pediatr Qual Saf 2021; 6:e385. [PMID: 34963998 PMCID: PMC8702256 DOI: 10.1097/pq9.0000000000000385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/18/2021] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Many quality improvement interventions do not lead to sustained improvement, and the sustainability of healthcare interventions remains understudied. We conducted a time-series analysis to determine whether improvements in the safety of rapid sequence intubation (RSI) in our academic pediatric emergency department were sustained 5 years after a quality improvement initiative.
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10
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Cobb MJ. Just Breathe: Tips and Highlights for Managing Pediatric Respiratory Distress and Failure. Emerg Med Clin North Am 2021; 39:493-508. [PMID: 34215399 DOI: 10.1016/j.emc.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Anatomically, the airway is ever changing in size, anteroposterior alignment, and point of most narrow dimension. Special considerations regarding obesity, chronic and acute illness, underlying developmental abnormalities, and age can all affect preparation and intervention toward securing a definitive airway. Mechanical ventilation strategies should focus on limiting peak inspiratory pressures and optimizing lung protective tidal volumes. Emergency physicians should work toward minimizing risk of peri-intubation hypoxemia and arrest. With review of anatomic and physiologic principles in the setting of a practical approach toward evaluating and managing distress and failure, emergency physicians can successfully manage critical pediatric airway encounters.
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Affiliation(s)
- Megan J Cobb
- University of Maryland School of Medicine, Department of Emergency Medicine; Maryland Emergency Medicine Network, Upper Chesapeake Emergency Medicine, 500 Upper Chesapeake Dr, Bel Air, MD 21014, USA.
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11
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April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, Brown CA. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation 2021; 162:403-411. [PMID: 33684505 DOI: 10.1016/j.resuscitation.2021.02.039] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 01/21/2023]
Abstract
AIM To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. METHODS This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. RESULTS Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. CONCLUSIONS Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.
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Affiliation(s)
- Michael D April
- From the 40th Forward Resuscitative Surgical Detachment, 627th Hospital Center, Fort Carson, CO, USA; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Allyson Arana
- United States Army Institute of Surgical Research, San Antonio, TX, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, USA
| | - William T Davis
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Joshua J Oliver
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, WA, USA
| | - Shane M Summers
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Ryder Trauma Center, Miami, FL, USA
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Ron M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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12
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Pacheco GS, Hurst NB, Patanwala AE, Hypes C, Mosier JM, Sakles JC. First Pass Success Without Adverse Events Is Reduced Equally with Anatomically Difficult Airways and Physiologically Difficult Airways. West J Emerg Med 2021; 22:360-368. [PMID: 33856324 PMCID: PMC7972367 DOI: 10.5811/westjem.2020.10.48887] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/28/2020] [Indexed: 01/25/2023] Open
Abstract
Introduction The goal of emergency airway management is first pass success without adverse events (FPS-AE). Anatomically difficult airways are well appreciated to be an obstacle to this goal. However, little is known about the effect of the physiologically difficult airway with regard to FPS-AE. This study evaluates the effects of both anatomically and physiologically difficult airways on FPS-AE in patients undergoing rapid sequence intubation (RSI) in the emergency department (ED). Methods We analyzed prospectively recorded intubations in a continuous quality improvement database between July 1, 2014–June 30, 2018. Emergency medicine (EM) or emergency medicine/pediatric (EM-PEDS) residents recorded patient, operator, and procedural characteristics on all consecutive adult RSIs performed using a direct or video laryngoscope. The presence of specific anatomically and physiologically difficult airway characteristics were also documented by the operator. Patients were analyzed in four cohorts: 1) no anatomically or physiologically difficult airway characteristics; 2) one or more anatomically difficult airway characteristics; 3) one or more physiologically difficult airway characteristics; and 4) both anatomically and physiologically difficult airway characteristics. The primary outcome was FPS-AE. We performed a multivariable logistic regression analysis to determine the association between anatomically difficult airways or physiologically difficult airways and FPS-AE. Results A total of 1513 intubations met inclusion criteria and were analyzed. FPS-AE for patients without any difficult airway characteristics was 92.4%, but reduced to 82.1% (difference = −10.3%, 95% confidence interval (CI), −14.8% to −5.6%) with the presence of one or more anatomically difficult airway characteristics, and 81.7% (difference = −10.7%, 95% CI, −17.3% to −4.0%) with the presence of one or more physiologically difficult airway characteristics. FPS-AE was further reduced to 70.9% (difference = −21.4%, 95% CI, −27.0% to −16.0%) with the presence of both anatomically and physiologically difficult airway characteristics. The adjusted odds ratio (aOR) of FPS-AE was 0.37 [95% CI, 0.21 – 0.66] in patients with anatomically difficult airway characteristics and 0.36 [95% CI, 0.19 – 0.67] for patients with physiologically difficult airway characteristics, compared to patients with no difficult airway characteristics. Patients who had both anatomically and physiologically difficult airway characteristics had a further decreased aOR of FPS-AE of 0.19 [95% CI, 0.11 – 0.33]. Conclusion FPS-AE is reduced to a similar degree in patients with anatomically and physiologically difficult airways. Operators should assess and plan for potential physiologic difficulty as is routinely done for anatomically difficulty airways. Optimization strategies to improve FPS-AE for patients with physiologically difficult airways should be studied in randomized controlled trials.
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Affiliation(s)
- Garrett S Pacheco
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
| | - Nicholas B Hurst
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
| | - Asad E Patanwala
- The University of Sydney School of Pharmacy, Royal Prince Alfred Hospital, NSW, Sydney, Australia
| | - Cameron Hypes
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona.,University of Arizona College of Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Tucson, Arizona
| | - Jarrod M Mosier
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona.,University of Arizona College of Medicine, Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, Tucson, Arizona
| | - John C Sakles
- University of Arizona College of Medicine, Department of Emergency Medicine, Tucson, Arizona
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Dean PN, Hoehn EF, Geis GL, Frey ME, Cabrera‐Thurman MK, Kerrey BT, Zhang Y, Stalets EL, Zackoff MW, Maxwell AR, Pham TM, Lautz AJ. Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department. Acad Emerg Med 2020; 27:1241-1248. [PMID: 32896033 DOI: 10.1111/acem.14128] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED). METHODS This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria. RESULTS Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively. CONCLUSIONS We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.
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Affiliation(s)
- Preston N. Dean
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Erin F. Hoehn
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- the Division of Emergency Medicine Children's Hospital of Pittsburgh of UPMC Pittsburgh PAUSA
| | - Gary L. Geis
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Mary E. Frey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Mary K. Cabrera‐Thurman
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Benjamin T. Kerrey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Yin Zhang
- the Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Erika L. Stalets
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Matthew W. Zackoff
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrea R. Maxwell
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Tena M. Pham
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrew J. Lautz
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
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