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Thomas P, Kerrey B, Edmunds K, Dean P, Frey M, Boyd S, Geis G, Ahaus K, Zhang Y, Sobolewski B. Video-Based Study of the Progression of Pediatric Emergency Medicine Fellows' Tracheal Intubation Performance During Training. Pediatr Emerg Care 2024:00006565-990000000-00508. [PMID: 39173190 DOI: 10.1097/pec.0000000000003204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The lower clinical exposure of Pediatric Emergency Medicine (PEM) fellows to critical procedures may impede skill acquisition. We sought to determine the tracheal intubation learning curve of PEM fellows during training and compared PEM fellow success against standards for tracheal intubation success. METHODS This was a retrospective, video-based study of a cohort of PEM fellows at a single academic pediatric emergency department (PED). All forms of tracheal intubation were included (rapid sequence intubation and crash or no medication). The cohort consisted of 36 PEM fellows from all or part of 5 consecutive fellowship classes. Data were collected by structured review of both existing ceiling-mounted videos and the electronic medical record. The main outcome was PEM fellows' success on the first or second attempt. We used cumulative summation to generate tracheal intubation learning curves. We specifically assessed the proportion of PEM fellows who reached 1 of 4 thresholds for procedural performance: 90% and 80% predicted success on the first and the first or second attempt. RESULTS From July 2014 to June 2020, there were 610 patient encounters with at least 1 attempt at tracheal intubation. The 36 PEM fellows performed at least 1 attempt at tracheal intubation for 414 ED patient encounters (65%). Median patient age was 2.1 years (interquartile range, 0.4-8.1). The PEM fellows were successful on the first attempt for 276 patients (67%) and on the first or second attempt for 337 (81%). None of the 36 PEM fellows reached the 90% threshold for either first or second attempt success. Four fellows (11%) met the 80% threshold for first attempt success and 11 (31%) met the 80% threshold for first or second attempt success. CONCLUSIONS Despite performing the majority of attempts, PEM fellows often failed to reach the standard thresholds for performance of tracheal intubation. Clinical exposure alone is too low to ensure acquisition of airway skills.
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Affiliation(s)
| | | | | | | | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | | | | | - Karen Ahaus
- Division of Respiratory Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yin Zhang
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
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Davis DP, Chandran K, Noce J. A Descriptive Analysis of Air Medical Pediatric Rapid Sequence Intubation: Successes and Opportunities. Air Med J 2024; 43:210-215. [PMID: 38821700 DOI: 10.1016/j.amj.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement. METHODS All pediatric patients (age < 18 years) undergoing RSI by air medical crews between 2015 and 2019 were included in this analysis. Subjects were divided a priori into 3 age subgroups (0-2 years, 3-8 years, and 9-17 years). The primary variables of interest included overall intubation success, first-attempt intubation success, and first-attempt intubation success without desaturation. The rates of positive-pressure ventilation (PPV) use for preoxygenation and oxygen desaturation were also explored. RESULTS A total of 1,091 pediatric RSI patients were included. The overall intubation success rate was 98% (0-2 years = 96%, 3-8 years = 97%, and 9-17 years = 98%), with 91% intubated on the first attempt (0-2 years = 86%, 3-8 years = 90%, and 9-17 years = 92%) and 87% intubated on the first attempt without oxygen desaturation (0-2 years = 80%, 3-8 years = 88%, and 9-17 years = 90%). A sharp decline in intubation success was observed with preoxygenation SpO2 values < 97% across all patients. Younger patients (0-2 years) had lower initial SpO2 values and decreased first-attempt success rates with and without desaturation. These patients were less likely to receive PPV during preoxygenation attempts and had lower use of video laryngoscopy or a bougie on the initial intubation attempt. CONCLUSION In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO2 values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.
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Affiliation(s)
- Daniel P Davis
- Logan Health, Division of EMS, Kalispell, MT; Air Methods Corporation, Greenwood Village, CO.
| | - Kira Chandran
- Georgetown School of Medicine, Georgetown, Washington DC; Harvard Affiliated Emergency Medicine Program, Boston, MA
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Rebollar RE, Hierro PL, Fernández AMMA. Delayed Sequence Intubation in Children, Why Not? SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:117-124. [PMID: 38764564 PMCID: PMC11098273 DOI: 10.4103/sjmms.sjmms_612_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/08/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Tracheal intubation in pediatric patients is a clinical scenario that can quickly become an emergency. Complication rates can potentially reach up to 60% in rapid sequence intubation. An alternate to this is delayed sequence intubation, which may reduce potential complications-mostly hypoxemia-and can be especially useful in non-cooperative children. This technique consists of the prior airway and oxygenation optimization. This is done through sedation using agents that preserve ventilatory function and protective reflexes and continuous oxygen therapy-prior and after the anesthetic induction-using nasal prongs. The objective of this narrative review is to provide a broader perspective on delayed sequence intubation by defining the concept and indications; reviewing its safety, effectiveness, and complications; and describing the anesthetic agents and oxygen therapy techniques used in this procedure.
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Affiliation(s)
- Ramón Eizaga Rebollar
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
| | - Paula Lozano Hierro
- Department of Anesthesiology and Reanimation, Puerta del Mar University Hospital, Cádiz, Spain\
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4
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Wolfgang M, Labudde EJ, Ruff K, Geis G, Frey M, Boyd S, Harun N, Kerrey BT. Structured Callouts, the Shared Mental Model, and Teamwork: A Video-Based Study in a Pediatric Emergency Department. Pediatr Emerg Care 2024; 40:203-207. [PMID: 37039447 DOI: 10.1097/pec.0000000000002939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVES The shared mental model is essential to high-quality resuscitations. A structured callout (SCO) is often performed to establish the shared mental model, but the literature on SCOs is limited. The objectives of this study are to describe performance of SCOs during pediatric medical emergencies and to determine whether a SCO is associated with better teamwork. METHODS This was a retrospective study in the resuscitation area of an academic pediatric emergency department, where performance of a SCO is a standard expectation. Only medical or nontrauma patients were eligible for inclusion. Data collection was performed by structured video review by 2 observers and verified by a third blinded observer. A SCO was defined as team leader (Pediatric Emergency Medicine fellow or faculty physician) verbalization of at least 1 element of the patient history/examination or an assessment of patient physiology and 1 element of the diagnostic or therapeutic plan. We independently measured teamwork using the Teamwork Emergency Assessment Measure (TEAM) tool. RESULTS We reviewed 60 patient encounters from the pediatric emergency department resuscitation area between April 2018 and June 2020. Median patient age was 6 years; the team leader was a Pediatric Emergency Medicine fellow in 55% of encounters. The physician team leader performed a SCO in 38 (63%) of patient encounters. The TEAM scores were collected for 46 encounters. Mean TEAM score (SD) was 42.3 (1.7) in patients with a SCO compared with 40.0 (3.0) in those without a SCO ( P = 0.007). CONCLUSIONS Performance of a SCO was associated with better teamwork, but the difference was of unclear clinical significance.
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Affiliation(s)
- Matthew Wolfgang
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Emily J Labudde
- Pediatric Residency Program, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kristen Ruff
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Mary Frey
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephanie Boyd
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nusrat Harun
- From the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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5
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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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Pacheco GS, Leetch AN, Patanwala AE, Hurst NB, Mendelson JS, Sakles JC. The Pediatric Rigid Stylet Improves First-Pass Success Compared With the Standard Malleable Stylet and Tracheal Tube Introducer in a Simulated Pediatric Emergency Intubation. Pediatr Emerg Care 2023; 39:423-427. [PMID: 35876757 DOI: 10.1097/pec.0000000000002802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pediatric emergency intubation is a high-acuity, low-occurrence procedure. Despite advances in technology, the success of this procedure remains low and adverse events are very high. Prospective observational studies in children have demonstrated improved success with the use of video laryngoscopy (VL) compared with direct laryngoscopy, although reported first-pass success (FPS) rates are lower than that reported for adults. This may in part be due to difficulty directing the tracheal tube to the laryngeal inlet considering the cephalad position of the larynx in infants. Using airway adjuncts such as the pediatric rigid stylet (PRS) or a tracheal tube introducer (TTI) may aid with intubation to the cephalad positioned airway when performing VL. The objectives of this study were to assess the FPS and time to intubation when intubating an infant manikin with a standard malleable stylet (SMS) compared with a PRS and TTI. METHODS This was a randomized cross-over study performed at an academic institution both with emergency medicine (EM) and combined pediatric and EM (EM&PEDS) residency programs. Emergency medicine and EM&PEDS residents were recruited to participate. Each resident performed intubations on a 6-month-old infant simulator using a standard geometry C-MAC Miller 1 video laryngoscope and 3 different intubation adjuncts (SMS, PRS, TTI) in a randomized fashion. All sessions were video recorded for data analysis. The primary outcome was FPS using the 3 different intubation adjuncts. The secondary outcome was the mean time to intubation (in seconds) for each adjunct. RESULTS Fifty-one participants performed 227 intubations. First-pass success with the SMS was 73% (37/51), FPS was 94% (48/51) with the PRS, and 29% (15/51) with the TTI. First-pass success was lower with the SMS (-43%; 95% confidence interval [CI], -63% to -23%; P < 0.01) and significantly lower with the TTI compared with PRS (difference -65%; 95% CI, -81% to -49%; P < 0.01). First-pass success while using the PRS was higher than SMS (difference 22%, 7% to 36%; P < 0.01). The mean time to intubation using the SMS was 44 ± 13 seconds, the PRS was 38 ± 11 seconds, and TTI was 59 ± 15 seconds. The mean time to intubation was higher with SMS (difference 15 seconds; 95% CI, 10 to 20 seconds; P < 0.01) and significantly higher with the TTI compared with PRS (difference 21 seconds; 95% CI, 17 to 26 seconds; P < 0.01). Time to intubation with the PRS was lower than SMS (difference -7 seconds; 95% CI, -11 to -2 seconds; P < 0.01). The ease of use was significantly higher for the PRS compared with the TTI when operators rated them on a visual analog scale (91 vs 20 mm). CONCLUSIONS Use of the PRS by EM and EM&PEDS residents on an infant simulator was associated with increased FPS and shorter time to intubation. Clinical studies are warranted comparing these intubation aids in children.
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Affiliation(s)
| | | | - Asad E Patanwala
- The University of Sydney School of Pharmacy Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Miller KA, Auerbach M, Bin SS, Donoghue A, Kerrey BT, Mittiga MR, D'Ambrosi G, Monuteaux MC, Marchese A, Nagler J. Coaching the coach: A randomized controlled study of a novel curriculum for procedural coaching during intubation. AEM EDUCATION AND TRAINING 2023; 7:e10846. [PMID: 36936084 PMCID: PMC10014969 DOI: 10.1002/aet2.10846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 06/18/2023]
Abstract
Background Videolaryngoscopy allows real-time procedural coaching during intubation. This study sought to develop and assess an online curriculum to train pediatric emergency medicine attending physicians to deliver procedural coaching during intubation. Methods Curriculum development consisted of semistructured interviews with 12 pediatric emergency medicine attendings with varying levels of airway expertise analyzed using a constructivist grounded theory approach. Following development, the curriculum was implemented and assessed through a multicenter randomized controlled trial enrolling participants in one of three cohorts: the coaching module, unnarrated video recordings of intubations, and a module on ventilator management. Participants completed identical pre and post assessments asking them to select the correct coaching feedback and provided reactions for qualitative thematic analysis. Results Content from interviews was synthesized into a video-enhanced 15-min online coaching module illustrating proper technique for intubation and strategies for procedural coaching. Eighty-seven of 104 randomized physicians enrolled in the curriculum; 83 completed the pre and post assessments (80%). The total percentage correct did not differ between pre and post assessments for any cohort. Participants receiving the coaching module demonstrated improved performance on patient preparation, made more suggestions for improvement, and experienced a greater increase in confidence in procedural coaching. Qualitative analysis identified multiple benefits of the module, revealed that exposure to video recordings without narration is insufficient, and identified feedback on suggestions for improvement as an opportunity for deliberate practice. Conclusions This study leveraged clinical and educational digital technology to develop a curriculum dedicated to the content expertise and coaching skills needed to provide feedback during intubations performed with videolaryngoscopy. This brief curriculum changed behavior in simulated coaching scenarios but would benefit from additional support for deliberate practice.
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Affiliation(s)
- Kelsey A. Miller
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Marc Auerbach
- Departments of Pediatrics and Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Steven S. Bin
- Departments of Pediatrics and Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Aaron Donoghue
- Department of Anesthesiology and Critical CarePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Benjamin T. Kerrey
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | | | | | | | - Ashley Marchese
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
| | - Joshua Nagler
- Department of PediatricsHarvard Medical SchoolBostonMassachusettsUSA
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8
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Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand T, Goldman MP, Prieto MM, Wing R, Breuer R, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes. Ann Emerg Med 2023; 81:113-122. [PMID: 36253297 DOI: 10.1016/j.annemergmed.2022.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/08/2022] [Accepted: 08/10/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVE To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA.
| | | | - Andrew F Miller
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
| | - Phillip M Thomas
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's, Cincinnati, OH
| | - Tara Neubrand
- Department of Emergency Medicine - Pediatric Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, CT
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, RI
| | - Ryan Breuer
- Department of Pediatrics - Pediatric Critical Care, Oishei Children's Hospital, Buffalo, NY
| | - Jenn D'Mello
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, MA
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9
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Hagiwara Y, Goto T, Ohnishi S, Miyamoto D, Ikeyama Y, Matsunami K, Hasegawa K. Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study. Acute Med Surg 2022; 9:e798. [PMID: 36203851 PMCID: PMC9525619 DOI: 10.1002/ams2.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 09/14/2022] [Indexed: 11/09/2022] Open
Abstract
Aim Tracheal intubation is a vital resuscitation procedure in the pediatric emergency department (ED). Despite its importance, little is known about the current status of emergency airway management in Japan. In this context, we aimed to investigate the airway management characteristics-particularly the location, patient, and provider factors-in the pediatric ED. Methods We conducted a multicenter, prospective study of five pediatric EDs in Japan from October 2018 to June 2020. The study included all children (aged ≤18 years) who underwent intubation at the pre-ED or ED setting by physicians and those who were transferred from the ED to the operation room (OR) or pediatric intensive care unit (PICU) for intubation. We described the airway management characteristics according to the location, patient, and provider factors. Results Of 231 children, 9 (4%) were transferred to the OR or PICU for airway management. Among the remaining 222 children, 45 were intubated at the pre-ED setting and 177 were intubated in the ED. The overall first-attempt success rate was 72%, with the rate varying by location, patient, and provider factors-for example, 68% at the pre-ED setting, 67% for children <2 years, 56% for children with airway-related anatomical anomalies, and 61% with intubation by a resident physician. Intubation-related adverse events were observed in 17%, most of which were hypoxemia (14%). Conclusions Based on data from a multicenter prospective study, the overall first-attempt intubation success rate in pediatric EDs in Japan was 72%, with large variations by location, patient, and provider factors.
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Affiliation(s)
- Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care MedicineTokyo Metropolitan Children's Medical CenterTokyoJapan
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public HealthThe University of TokyoTokyoJapan
| | - Shima Ohnishi
- Division of Emergency and Transport ServicesNational Center for Child Health and DevelopmentTokyoJapan
| | - Daisuke Miyamoto
- Department of Pediatric Emergency MedicineSaitama Children's Medical CenterSaitamaJapan
| | - Yuki Ikeyama
- Department of Pediatric Emergency MedicineAichi Children's Health and Medical CenterObu‐shi, AichiJapan
| | - Kunihiro Matsunami
- Department of PediatricsGifu Prefectural General Medical CenterGifuJapan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMA
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10
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Lee JY, Lee SU, Son MH, Park JW, Jung JY, Kim JH. Factors Associated with the Underuse of Sedatives and Neuromuscular Blocking Agents for Pediatric Emergency Endotracheal Intubation in Korea. Yonsei Med J 2022; 63:767-773. [PMID: 35914759 PMCID: PMC9344268 DOI: 10.3349/ymj.2022.63.8.767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/01/2022] [Accepted: 06/07/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Rapid sequence intubation (RSI) using sedatives and neuromuscular blocking agents (NMBAs) is recommended for pediatric emergency endotracheal intubation (ETI), but is not frequently performed in Korea. This study aimed to verify factors associated with the underuse of RSI medications. MATERIALS AND METHODS This multicenter retrospective study reviewed patients aged under 18 years who underwent an ETI within 24 hours of arrival at the emergency department between 2016 and 2019. Any cases of ETI during cardiopulmonary resuscitation were excluded. We investigated the characteristics of the patients, intubators, RSI medications, and outcomes. The study cases were classified into no-medication, sedative-only, and sedative-with-NMBA groups. Multivariable logistic regression analysis of RSI medication use was conducted. RESULTS A total of 334 cases with a median age of 3.4 years were included in this study. Sedatives and NMBAs were used in 63.8% and 32.9%, respectively. In comparing the no-medication (n=121), sedative-only (n=103), and sedative-with-NMBA (n=110) groups, patient age (median; 1.0 year vs. 2.8 years vs. 11.3 years; p<0.001), underlying medical conditions (77.7% vs. 56.3% vs. 36.4%; p<0.001), and pediatricians as intubators (76.9% vs. 54.4% vs. 17.3%; p<0.001) were different. The factors that influenced sedatives with NMBA use were patient age [for a year increment; adjusted odds ratio (aOR), 1.182; 95% confidence interval (CI), 1.120-1.249], no underlying medical conditions (aOR, 2.109; 95% CI, 1.093-4.070), and intubators other than pediatricians (aOR, 5.123; 95% CI, 2.257-11.626). CONCLUSION RSI accounted for 32.9% of pediatric emergency ETI in Korea. The underuse of RSI medications is associated with younger patient age, underlying medical conditions, and pediatricians as intubators.
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Affiliation(s)
- Jeong-Yong Lee
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Seoul, Korea
| | - Meong Hi Son
- Department of Pediatrics, Samsung Medical Center, Seoul, Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea.
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11
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Edmunds K, Pierpoint S, Frey M, Ahaus K, Boyd S, Shah A, Zhang Y, Kerrey B. Fraction of Expired Oxygen as a Measure of Preoxygenation Prior to Rapid Sequence Intubation in the Pediatric Emergency Department. J Emerg Med 2022; 63:62-71. [PMID: 35933262 DOI: 10.1016/j.jemermed.2022.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/08/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pulse oximetry (SpO2) is a flawed measure of adequacy of preoxygenation prior to intubation. The fraction of expired oxygen (FeO2) is a promising but understudied alternative. OBJECTIVE To investigate FeO2 as a measure of preoxygenation prior to intubation in a pediatric emergency department. METHODS We conducted a prospective, observational study of patients 18 and younger. We collected data using video review, and FeO2 was measured via inline sampling. The main outcomes were FeO2 and SpO2 at the start of preoxygenation, end of preoxygenation/start of intubation attempt, and the end of intubation attempt. We compared FeO2 and SpO2 at the end of preoxygenation for patients with and without oxyhemoglobin desaturation. RESULTS We enrolled 85 of 88 eligible patients during the 14-month study period. FeO2 data were available at the start of preoxygenation for 53 of 85 patients (62%), and for the end of preoxygenation for 59 of 85 patients (69%). Median FeO2 at the start and end of preoxygenation was 90% (interquartile range [IQR] 88, 92) and 90% (IQR 88, 92). Median SpO2 at the start and end of preoxygenation was 100% (IQR 100, 100). There were 11 episodes of desaturation, with median FeO2 at the start of intubation attempt of 89.5 (IQR 54.5, 91.5) and median SpO2 of 100 (IQR 99, 100). Patients who did not have a desaturation event had a median FeO2 of 90.0 (IQR 88.0, 92.0). CONCLUSIONS Measuring FeO2 during rapid sequence intubation is challenging with feasibility limitations, but may be a more discriminatory metric of adequate preoxygenation.
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Affiliation(s)
- Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio.
| | - Sara Pierpoint
- University of Cincinnati, College of Medicine, Cincinnati, Ohio
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Karen Ahaus
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashish Shah
- Division of Pediatric Emergency Medicine, Rady Children's Hospital, San Diego, California; Department of Pediatrics, University of California - San Diego, San Diego, California
| | - Yin Zhang
- Division of Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Benjamin Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio
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12
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Impact of Intubator's Training Level on First-Pass Success of Endotracheal Intubation in Acute Care Settings: A Four-Center Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9070960. [PMID: 35883944 PMCID: PMC9322935 DOI: 10.3390/children9070960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
(1) Background: First-pass success (FPS) of endotracheal intubation is more challenging in children than in adults. We aimed to identify factors associated with FPS of intubation in acute care settings. (2) Methods: We analyzed data of children aged <10 years who underwent intubation within ≤24 h of arrival at four Korean emergency departments (2016−2019). Variables were compared according to FPS. A logistic regression was performed to quantify the association of factors with FPS. An experienced intubator was defined as a senior resident or a specialist. (3) Results: Of 280 children, 169 (60.4%) had FPS. The children with FPS were older (median age, 23.0 vs. 11.0 months; p = 0.018), were less frequently in their infancy (36.1% vs. 50.5%; p = 0.017), and were less likely to have respiratory compromise (41.4% vs. 55.0%; p = 0.030). The children with FPS tended to be more often intubated by experienced intubators than those without FPS (87.0% vs. 78.4%; p = 0.057). Desaturation was rarer in those with FPS. Factors associated with FPS were experienced intubators (aOR, 1.93; 95% CI, 1.01−3.67) and children’s age ≥12 months (1.84; 1.13−3.02). (4) Conclusion: FPS of intubation can be facilitated by deploying or developing clinically competent intubators, particularly for infants, in acute care settings.
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13
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Aroonpruksakul N, Sangsungnern P, Kiatchai T. Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial. Transl Pediatr 2022; 11:427-437. [PMID: 35558969 PMCID: PMC9085956 DOI: 10.21037/tp-21-484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 02/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction. METHODS This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO2) ≤92%. RESULTS Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO2 was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069). CONCLUSIONS In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII. TRIAL REGISTRATION Thai Clinical Trials Registry TCTR20210802002.
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Affiliation(s)
- Naiyana Aroonpruksakul
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Peerapong Sangsungnern
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Taniga Kiatchai
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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14
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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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15
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Shah A, Edmunds K, Dean P, Frey M, Boyd S, Ahaus K, Zhang Y, Varadarajan K, Kerrey BT. Don't Hold Your Breath-A Video-Based Study of Procedural Intervals During Pediatric Rapid Sequence Intubation. Pediatr Emerg Care 2022; 38:e784-e790. [PMID: 35100777 DOI: 10.1097/pec.0000000000002340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Develop a framework for data collection to determine the contributions of both laryngoscopy and tube delivery intervals to the apneic period in unsuccessful and successful attempts among patients undergoing rapid sequence intubation (RSI) in a pediatric emergency department (PED). DESIGN This was a retrospective, observational study of RSI. SETTING An academic PED. PATIENTS A consecutive sample of all intubations attempts of first provider physicians performing RSI in the shock trauma suite over a 10-month period in 2018-2019. MEASUREMENT AND MAIN RESULTS Data were collected by structured video review. The main outcome was the duration of the laryngoscopy and tube delivery intervals per attempt. We compared interval duration between successful and unsuccessful attempts, adjusting for age, accounting for repeated measures, and clustering by provider. There were 69 patients with 89 total intubation attempts. Sixty-three patients were successfully intubated by the first provider (91%). Pediatric emergency medicine fellows performed 54% of the attempts. The median duration of the apneic period per attempt was longer in unsuccessful attempts (57 vs 44 seconds; median of difference, -10.5; 95% confidence interval [CI], -17.0 to -4.0). The duration of laryngoscopy was similar (18 vs 13 seconds; median of difference, -3.5; 95% CI, -8.0 to 1.0), but tube delivery was longer in unsuccessful attempts (25.5 vs. 11 seconds; median of difference, -12.5; 95% CI, -17.0 to -4.0). These results did not change when adjusting for age or clustering by provider. CONCLUSIONS We successfully developed a specific, time-based framework for the contributors to prolonged apnea in RSI. Prolonged tube delivery accounted for more of the apneic period. Future studies and improvement should focus on problems during tube delivery in the PED.
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Affiliation(s)
| | | | - Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
| | - Karen Ahaus
- University of Cincinnati College of Medicine
| | - Yin Zhang
- University of Cincinnati College of Medicine
| | - Kartik Varadarajan
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center
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16
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Er A, Çağlar A, Çitlenbik H, Akgül F, Ulusoy E, Ören H, Yιlmaz D, Duman M. Which Device Is Favorable for Intubation Attempts of Pediatric Residents on Four Different Pediatric Airway Simulations? Pediatr Emerg Care 2022; 38:e272-e277. [PMID: 33003132 DOI: 10.1097/pec.0000000000002247] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Endotracheal intubation is an essential skill for the pediatric airway management. Although direct laryngoscopy (DL) is the standard method, several videolaryngoscopes (VLs) have been recently enhanced as an alternative especially for difficult intubations. We aimed to compare McGrath MAC (McG) and Storz C-MAC PM (ST) VLs with DL in terms of intubation success rate, time to intubation (TTI), and duration of obtaining glottis view of intubation attempts performed by pediatric residents on different pediatric airway manikins. METHODS The pediatric residents with no experience in videolaryngoscopy were included. After a brief demonstration, intubation attempts with 3 randomly handled different devices with 6 different blades were performed on a child manikin, an infant manikin, a Pierre-Robin sequence infant manikin, and a child manikin with cervical immobilization sequentially. RESULTS Fifty pediatric residents were enrolled. The attempts of DL on child manikin and attempts of all devices on child with cervical immobilization simulation were completely successful. For the attempts on both infant manikin and Pierre-Robin sequence infant manikin, the success rate of McG was significantly lower than ST and DL (P = 0.011 and P = 0.001). In the child manikin, McG and ST had prolonged TTI compared with DL (P = 0.016 and P = 0.001). For the child with cervical immobilization simulation, TTI of DL was significantly shorter than McG and ST (P = 0.011 and P = 0.001). Time to intubation of McG was significantly longer than DL and ST for the attempts on both 2 infant manikins. The rate of Cormack-Lehane grade I glottis view was similar for the attempts on both 2 child airway simulations. For infant manikin and Pierre-Robin sequence infant simulation, the rate of Cormack-Lehane grade I of ST was higher than attempts of DL and McG. CONCLUSIONS The attempts of pediatric residents on infant normal airway and Pierre-Robin sequence infant airway simulations resulted with enhanced glottis view by the utilization of Storz C-MAC PM, but both 2 VLs did not provide the improvement of intubation success rate and TTI compared with DL on these 4 different pediatric manikins. Further clinical studies of different VLs in different clinical courses are required for a reliable utilization in children.
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Affiliation(s)
- Anıl Er
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Aykut Çağlar
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Hale Çitlenbik
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Fatma Akgül
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Emel Ulusoy
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Hale Ören
- Department of Pediatrics, Dokuz Eylul University, School of Medicine, Izmir, Turkey
| | - Durgül Yιlmaz
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
| | - Murat Duman
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics
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17
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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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18
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Abid ES, Miller KA, Monuteaux MC, Nagler J. Association between the number of endotracheal intubation attempts and rates of adverse events in a paediatric emergency department. Emerg Med J 2021; 39:601-607. [PMID: 34872932 DOI: 10.1136/emermed-2021-211570] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/13/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Challenges in emergent airway management in children can affect intubation success. It is unknown if number of endotracheal intubation attempts is associated with rates of adverse events in the paediatric ED setting. OBJECTIVE We sought to (1) Identify rates of intubation-related adverse events, (2) Evaluate the association between the number of intubation attempts and adverse events in a paediatric ED, and (3) Determine the effect of videolaryngoscopy on these associations. DESIGN AND METHODS We performed a retrospective observational study of patients who underwent endotracheal intubation in a paediatric ED in the USA between January 2004 and December 2018. Data on patient-related, provider-related and procedure-related characteristics were obtained from a quality assurance database and the health record. Our primary outcome was frequency of intubation-related adverse events, categorised as major and minor. The number of intubation attempts was trichotomised to 1, 2, and 3 or greater. Multivariable logistic regression models were used to determine the relationship between the number of intubation attempts and odds of adverse events, adjusting for demographic and clinical factors. RESULTS During the study period, 628 patients were intubated in the ED. The overall rate of adverse events was 39%. Hypoxia (19%) was the most common major event and mainstem intubation (15%) the most common minor event. 72% patients were successfully intubated on the first attempt. With two intubation attempts, the adjusted odds of any adverse event were 3.26 (95% CI 2.11 to 5.03) and with ≥3 attempts the odds were 4.59 (95% CI 2.23 to 9.46). Odds similarly increased in analyses of both major and minor adverse events. This association was consistent for both traditional and videolaryngoscopy. CONCLUSION Increasing number of endotracheal intubation attempts was associated with higher odds of adverse events. Efforts to optimise first attempt success in children undergoing intubation may mitigate this risk and improve clinical outcomes.
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Affiliation(s)
- Edir S Abid
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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19
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To YH, Ong YKG, Chong SL, Ang PH, Bte Zakaria ND, Lee KP, Pek JH. Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments. Paediatr Anaesth 2021; 31:713-719. [PMID: 33774880 DOI: 10.1111/pan.14185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/26/2021] [Accepted: 03/22/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies. AIMS We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs. METHODS A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16 years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubation-associated events were collected and analyzed. RESULTS There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2 years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED. Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p = .558). There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p = .037). CONCLUSIONS Differences exist in intubation outcomes between pediatric and general EDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.
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Affiliation(s)
- Yi Hui To
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Peck Har Ang
- Accident & Emergency Department, Changi General Hospital, SingHealth, Singapore City, Singapore
| | - Nur Diana Bte Zakaria
- Department of Emergency Medicine, Singapore General Hospital, SingHealth, Singapore City, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, SingHealth, Singapore City, Singapore
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20
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Anil AB, Anil M, Durak F, Altuğ Ü, Özçifçi G, Yalçın G, Demir Ş. Comparison of direct and video laryngoscope endotracheal intubations by pediatric residents: A study of a child model with normal airway. Turk Arch Pediatr 2021; 56:224-229. [PMID: 34104913 DOI: 10.5152/turkarchpediatr.2021.20074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/22/2020] [Indexed: 11/22/2022]
Abstract
Objective This study aimed to compare the efficacy of direct and videolaryngoscopy procedures performed by pediatric residents who had limited experience of direct endotracheal intubation and had not previously used video laryngoscopes in a normal airway child manikin. Material and Methods The endotracheal intubations performed by pediatric residents with a direct laryngoscope and Storz C-MAC videolaryngoscope on a pediatric manikin with a normal airway were compared. Theoretical and practical training was given before the study. In the first attempt, the success of the intubation procedure, glottis visual duration, and endotracheal tube insertion time were determined. Practitioners grouped the glottis image between 1-4 according to the Cormack-Lehane Staging (Stage 1 ideal image). After the intervention, the participants scored one to ten points on direct and videolaryngoscopy (1 not useful, 10 very useful). Results The success of direct and videolaryngoscopy of 51 pediatric residents on the same manikin was 48 out of 51 (94%) for each method (P> 0.05). Glottis visual duration was similar in both methods (P>0.05); tube insertion and total intubation time were shorter in the video laryngoscope group (P<0.05); glottis image was better in the video laryngoscope group according to Cormack-Lehane Classification (P<0.05). Participants' rating was higher on videolaryngoscope (P<0.05). Conclusion Users with limited endotracheal intubation experience use Video laryncoscope more effectively than direct laryngoscope in children with normal airway model after training.
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Affiliation(s)
- Ayşe Berna Anil
- Department of Pediatric Intensive Care Unit, İzmir Katip Çelebi University, School of Medicine, İzmir,Turkey
| | - Murat Anil
- Pediatric Emergency Clinic, University of Health Sciences Tepecik Training and Research Hospital Izmir, Turkey
| | - Fatih Durak
- Pediatric Intensive Care Clinic, University of Health Sciences, Tepecik Training and Research Hospital İzmir, Turkey
| | - Ümüt Altuğ
- Pediatric Intensive Care Clinic, University of Health Sciences, Tepecik Training and Research Hospital İzmir, Turkey
| | - Gökçen Özçifçi
- Pediatric Intensive Care Clinic, University of Health Sciences, Tepecik Training and Research Hospital İzmir, Turkey
| | - Gülşen Yalçın
- Pediatric Emergency Clinic, University of Health Sciences Tepecik Training and Research Hospital Izmir, Turkey
| | - Şule Demir
- Pediatric Emergency Clinic, University of Health Sciences Tepecik Training and Research Hospital Izmir, Turkey
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21
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Ayanmanesh F, Abdat R, Jurine A, Azale M, Rousseaux G, Coulons S, Samain E, Brasher C, Julien-Marsollier F, Dahmani S. Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children. Anaesth Crit Care Pain Med 2021; 40:100817. [PMID: 33677095 DOI: 10.1016/j.accpm.2021.100817] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/13/2020] [Accepted: 10/31/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). METHODS In this prospective observational study, arterial desaturation < 95% SaO2 before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients' age (older or younger than 1 year). RESULTS Complete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01). CONCLUSIONS Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.
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Affiliation(s)
- Fanny Ayanmanesh
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Rachida Abdat
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Amélie Jurine
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Mehdi Azale
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Guillaume Rousseaux
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Sarah Coulons
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Emmanuel Samain
- Department of Anaesthesia and Intensive Care, Jean Minjoz Hospital, 3, Bd Alexandre Flemming, 25000 Besançon, France
| | - Christopher Brasher
- Department of Anaesthesia & Pain Management, Royal Children's Hospital, Melbourne, Australia; Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Florence Julien-Marsollier
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France
| | - Souhayl Dahmani
- Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France.
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22
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Mittiga MR, Frey M, Kerrey BT, Rinderknecht AS, Eckerle MD, Sobolewski B, Johnson LH, Oehler JL, Bennett BL, Chan S, Frey TM, Krummen KM, Lindsay C, Wolfangel K, Richert A, Masur TJ, Bria CL, Hoehn EF, Geis GL. The Medical Resuscitation Committee: Interprofessional Program Development to Optimize Care for Critically Ill Medical Patients in an Academic Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:167-171. [PMID: 30883536 DOI: 10.1097/pec.0000000000001742] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
ABSTRACT Provision of optimal care to critically ill patients in a pediatric emergency department is challenging. Specific challenges include the following: (a) patient presentations are highly variable, representing the full breadth of human disease and injury, and are often unannounced; (b) care team members have highly variable experience and skills and often few meaningful opportunities to practice care delivery as a team; (c) valid data collection, for quality assurance/improvement and clinical research, is limited when relying on traditional approaches such as medical record review or self-report; (d) specific patient presentations are relatively uncommon for individual providers, providing few opportunities to establish and refine the requisite knowledge and skill; and (e) unscientific or random variation in care delivery. In the current report, we describe our efforts for the last decade to address these challenges and optimize care delivery to critically ill patients in a pediatric emergency department. We specifically describe the grassroots development of an interprofessional medical resuscitation program. Key components of the program are as follows: (a) a database of all medical patients undergoing evaluation in the resuscitation suite, (b) peer review and education through video-based case review, (c) a program of emergency department in situ simulation, and (d) the development of cognitive aids for high-acuity, low-frequency medical emergencies.
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Affiliation(s)
| | - Mary Frey
- From the Division of Emergency Medicine
| | | | | | | | | | | | | | | | | | | | - Kelly M Krummen
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Claire Lindsay
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Kelsey Wolfangel
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Alison Richert
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Tonya J Masur
- Emergency Services, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH
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Hansen M, White L, Whitmore G, Lin A, Walker R. Vital sign monitoring during out-of-hospital pediatric advanced airway management. J Am Coll Emerg Physicians Open 2020; 1:1571-1577. [PMID: 33392565 PMCID: PMC7771744 DOI: 10.1002/emp2.12273] [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: 04/28/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate physiologic monitoring in pediatric patients undergoing out-of-hospital advanced airway management. METHODS Retrospective case series of pediatric patients (<18 years) with advanced airways placed in the out-of-hospital setting. Patients given cardiopulmonary resuscitation (CPR) or defibrillation before the first advanced airway attempt were excluded. Reviewers abstracted physiologic data from the patient monitor files and patient care reports. The primary outcome was the proportion of time pulse oximetry was in place during airway management. Other outcomes included the proportion of time ECG monitoring and waveform end-tidal capnography were in place as well as the incidence of oxygen desaturation events. RESULTS We evaluated 23 pediatric patients with a mean age of 10.7 years (SD 6.5). Eleven of 18 (61%) children with medication-facilitated intubation had pulse oximetry in place when the first medication was documented as given. Eight of 18 (44%) had ECG monitoring, 12 of 18 (66%) had waveform capnography, and 5 of 18 (28%) had a blood pressure check within the 3 minutes before receiving the first medication. In the 3-minute preoxygenation phase, pulse oximetry was in place for an average of 1.4 minutes (47%, SD 0.37) and a visible photoplethysmogram (PPG) waveform obtained from the pulse oximeter was present for 0.6 minutes (20%, SD 0.34). During airway device placement, pulse oximetry was in place 73% (SD 0.39) of the time and 30% (SD 0.41) of the time there was a visible PPG waveform. CONCLUSIONS Pediatric patients had critical deficits in physiologic monitoring during advanced airway management.
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Affiliation(s)
- Matt Hansen
- Center for Policy and Research in Emergency MedicineDepartment of Emergency Medicine at Oregon Health & Science UniversityPortlandOregonUSA
| | - Lynn White
- Global Medical ResponseGreenwood VillageColoradoUSA
| | | | - Amber Lin
- Center for Policy and Research in Emergency MedicineDepartment of Emergency Medicine at Oregon Health & Science UniversityPortlandOregonUSA
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24
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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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25
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Miller KA, Monuteaux MC, Nagler J. Technical factors associated with first-pass success during endotracheal intubation in children: analysis of videolaryngoscopy recordings. Emerg Med J 2020; 38:125-131. [PMID: 33172879 DOI: 10.1136/emermed-2020-209700] [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: 04/01/2020] [Revised: 09/16/2020] [Accepted: 10/04/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND First-pass success (FPS) during intubation is associated with lower morbidity for paediatric patients. Using videolaryngoscopy (VL) recordings, we reviewed technical aspects of intubation, including factors associated with FPS in children. METHODS We performed a retrospective study of intubation attempts performed using video-assisted laryngoscopy in a paediatric ED between January 2014 and December 2018. Data were abstracted from a quality assurance database, the electronic medical record and VL recordings. Our primary outcome was FPS. Intubation practices were analysed using descriptive statistics. Patient and procedural characteristics associated with FPS in univariate testing and clinical factors identified from the literature were included as covariates in a multivariable logistic regression. An exploratory analysis examined the relationship between position of the glottic opening on the video screen and FPS. RESULTS Intubation was performed during 237 patient encounters, with 231 using video-assisted laryngoscopy. Data from complete video recordings were available for 129 attempts (59%); an additional 31 (13%) had partial recordings. Overall, 173 (73%) of first attempts were successful. Adjusting for patient age, placing the blade tip into the vallecula adjusted OR ((aOR) 7.2 (95% CI 1.7 to 30.1)) and obtaining a grade 1 or 2a-modified Cormack-Lehane glottic view on the videolaryngoscope screen (aOR 6.1 (95% CI 1.5 to 25.7) relative to grade 2b) were associated with increased FPS in the subset of patients with complete recordings. Exploratory analysis suggested that FPS is highest (81%) and duration is shortest when the glottic opening is located in the second quintile of the video screen. CONCLUSIONS Placement of the blade tip into the vallecula regardless of blade type, sufficient glottic visualisation and locating the glottic opening within the second quintile of the video screen were associated with FPS using video-assisted laryngoscopy in the paediatric ED.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA .,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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26
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Optimizing Rapid Sequence Intubation for Medical and Trauma Patients in the Pediatric Emergency Department. Pediatr Qual Saf 2020; 5:e353. [PMID: 33062904 PMCID: PMC7523837 DOI: 10.1097/pq9.0000000000000353] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/23/2020] [Indexed: 11/26/2022] Open
Abstract
Introduction Rapid sequence intubation (RSI) is a critical procedure for severely ill and injured patients presenting to the pediatric emergency department (PED). This procedure has a high risk of complications, and multiple attempts increase this risk. We aimed to increase successful intubation within two attempts, focusing on medical and trauma patients separately to identify improvement barriers for each group. Methods A multifaceted intervention was implemented using quality improvement methods. The analysis included adherence to the standardized process, successful intubation within two attempts, and frequency of oxygen saturations <92% during laryngoscopy. Trauma and medical patients were analyzed separately as team composition differed for each. Results This project began in February 2018, and we included 290 patients between April 2018 and December 2019. Adherence to the standardized process was sustained at 91% for medical patients and a baseline of 55% for trauma patients with a trend toward improvement. In May 2018, we observed and sustained special cause variations for medical patients' successful intubations within two attempts (77-89%). In September 2018, special cause variation was observed and sustained for the successful intubation of trauma patients within two attempts (89-96%). The frequency of oxygen saturation of <92% was 21% for medical patients; only one trauma patient experienced oxygen desaturation. Conclusion Implementation of a standardized process significantly improved successful intubations within two attempts for medical and trauma patients. Trauma teams had more gradual adherence to the standardized process, which may be related to the relative infrequency of intubations and variable team composition.
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27
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Myers SR, Abbadessa MKF, Gaines S, Lavelle J, Ercolani JM, Shotwell C, Ainsley M, Pettijohn KW, Donoghue AJ. Repurposing Video Review Infrastructure for Clinical Resuscitation Care in the Age of COVID-19. Ann Emerg Med 2020; 77:110-116. [PMID: 33160721 PMCID: PMC7447219 DOI: 10.1016/j.annemergmed.2020.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Sage R Myers
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Mary Kate F Abbadessa
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Shannon Gaines
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jane Lavelle
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jenna M Ercolani
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Collin Shotwell
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matthew Ainsley
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kevin W Pettijohn
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aaron J Donoghue
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Resident Performance of the Rapid Cardiopulmonary Assessment in the Emergency Department. Pediatr Emerg Care 2020; 36:e304-e309. [PMID: 29794959 DOI: 10.1097/pec.0000000000001535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The rapid cardiopulmonary assessment (RCPA) is an essential first step in effective resuscitation of critically ill children. Pediatric residents may not be achieving competency with resuscitative skills, including RCPA. Our objective was to determine how often pediatric residents complete the RCPA for actual patients. METHODS This was an observational, cross-sectional study of senior residents (≥postgraduate year 2) performing the RCPA in the resuscitation area of a high-volume pediatric emergency department (PED), where pediatric residents are expected to perform the bedside examination and assessment for all medical (nontrauma) patients. Data were collected primarily by video review on a standard form. The primary outcome was completion of the RCPA, defined as both examination and verbalized assessment of the airway, breathing, and circulation. We explored the association between RCPA completion and both residency year and number of previous PED rotations. RESULTS Complete data were collected from one randomly selected patient for 71 (95%) of 75 of eligible senior residents who rotated in the PED between January and June 2013. Two residents (3%) performed a complete RCPA. Verbalized assessment of circulation was especially rare (7/71; 10%). There was no association between RCPA completion and year of training or previous PED experience (P > 0.05). CONCLUSIONS Senior pediatric resident performance of the RCPA in the resuscitation area of a high-volume PED was poor. There was no association between RCPA completion and greater resident experience, including in the PED. These findings add to a growing body of literature suggesting that pediatric residents are not achieving competency with the RCPA and resuscitation skills.
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Impact of Personal Protective Equipment on the Performance of Emergency Pediatric Procedures by Prehospital Providers. Disaster Med Public Health Prep 2020; 16:86-93. [PMID: 32389152 PMCID: PMC7385319 DOI: 10.1017/dmp.2020.128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background: Personal protective equipment (PPE) is worn by prehospital providers (PHPs) for protection from hazardous exposures. Evidence regarding the ability of PHPs to perform resuscitation procedures has been described in adult but not pediatric models. This study examined the effects of PPE on the ability of PHPs to perform resuscitation procedures on pediatric patients. Methods: This prospective study was conducted at a US simulation center. Paramedics wore normal attire at the baseline session and donned full Level B PPE for the second session. During each session, they performed timed sets of psychomotor tasks simulating clinical care of a critically ill pediatric patient. The difference in time to completion between baseline and PPE sessions per task was examined using Wilcoxon signed-rank tests. Results: A total of 50 paramedics completed both sessions. Median times for task completion at the PPE sessions increased significantly from baseline for several procedures: tracheal intubation (+4.5 s; P = 0.01), automated external defibrillator (AED) placement (+9.5 s; P = 0.01), intraosseous line insertion (+7 s; P < 0.0001), tourniquet (+8.5 s; P < 0.0001), intramuscular injection (+21-23 s, P < 0.0001), and pulse oximetry (+4 s; P < 0.0001). There was no significant increase in completion time for bag-mask ventilation or autoinjector use. Conclusions: PPE did not have a significant impact on PHPs performing critical tasks while caring for a pediatric patient with a highly infectious or chemical exposure. This information may guide PHPs faced with the situation of resuscitating children while wearing Level B PPE.
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Videography in Pediatric Emergency Research: Establishing a Multicenter Collaborative and Resuscitation Registry. Pediatr Emerg Care 2020; 36:222-228. [PMID: 32356959 DOI: 10.1097/pec.0000000000001531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES High-quality clinical research of resuscitations in a pediatric emergency department is challenging because of the limitations of traditional methods of data collection (chart review, self-report) and the low frequency of cases in a single center. To facilitate valid and reliable research for resuscitations in the pediatric emergency department, investigators from 3 pediatric centers, each with experience completing successful single-center, video-based studies, formed the Videography In Pediatric Emergency Research (VIPER) collaborative. METHODS Our initial effort was the development of a multicenter, video-based registry and simulation-based testing of the feasibility and reliability of the VIPER registry. Feasibility of data collection was assessed by the frequency of an indeterminate response for all data elements in the registry. Reliability was assessed by the calculation of Cohen κ for dichotomous data elements and intraclass correlation coefficients for continuous data elements. RESULTS Video-based data collection was completed for 8 simulated pediatric resuscitations, with at least 2 reviewers per case. Data were labeled as indeterminate by at least 1 reviewer for 18 (3%) of 524 relevant data fields. The Cohen κ for all dichotomous data fields together was 0.81 (95% confidence interval, 0.61-1.0). For all continuous (time-based) variables combined, the intraclass correlation coefficient was 0.88 (95% confidence interval, 0.70-0.96). CONCLUSIONS Initial simulation-based testing suggests video-based data collection using the VIPER registry is feasible and reliable. Our next step is to assess feasibility and reliability for actual pediatric resuscitations and to complete several prospective, hypothesis-based studies of specific aspects of resuscitative care, including of cardiopulmonary resuscitation, tracheal intubation, and teamwork and communication.
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Overmann KM, Boyd SD, Zhang Y, Kerrey BT. Apneic oxygenation to prevent oxyhemoglobin desaturation during rapid sequence intubation in a pediatric emergency department. Am J Emerg Med 2019; 37:1416-1421. [DOI: 10.1016/j.ajem.2018.10.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/09/2018] [Accepted: 10/17/2018] [Indexed: 10/28/2022] Open
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Abstract
Airway management is the cornerstone to resuscitation efforts for many critically ill pediatric patients presenting for emergency care. Pediatric endotracheal intubation is uncommon in emergency medicine, making it challenging to maintain comfort with this critical procedure. This article offers strategies to facilitate pediatric airway management by addressing predictable anatomic and physiologic differences in children. Also reviewed are alternative approaches to airway management (eg, noninvasive ventilation and videolaryngoscopy) that might be used in cases of recognized difficult airways. Finally, recommendations for maintaining procedural skills in providers who may have limited clinical exposure to critically ill children requiring airway interventions are provided.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Joshua Nagler
- Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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Driver BE, Scharber SK, Horton GB, Braude DA, Simpson NS, Reardon RF. Emergency Department Management of Out-of-Hospital Laryngeal Tubes. Ann Emerg Med 2019; 74:403-409. [PMID: 30826068 DOI: 10.1016/j.annemergmed.2019.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/09/2019] [Accepted: 01/10/2019] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVE Laryngeal tubes are commonly used by emergency medical services (EMS) personnel for out-of-hospital advanced airway management. The emergency department (ED) management of EMS-placed laryngeal tubes is unknown. We seek to describe ED airway management techniques, success, and complications of patients receiving EMS laryngeal tubes. METHODS Using a keyword text search of ED notes, we identified patients who arrived at our ED with a laryngeal tube from 2010 through 2017. We performed structured chart and video reviews for all eligible patients. In our ED, emergency physicians perform all airway management, and there is no protocol dictating airway management for patients arriving with a laryngeal tube. Using descriptive methods, we report the techniques, success, and complications of ED airway management. RESULTS We analyzed data on 647 patients receiving out-of-hospital laryngeal tubes, including 472 (73%) with cardiac arrest from medical causes, 75 (21%) with cardiac arrest from trauma, and 100 (15%) with other conditions. For 580 patients (89%), emergency physicians exchanged the laryngeal tube for a definitive airway in the ED. Of the 67 patients not intubated in the ED, 66 died in the ED without further airway management. Of the 580 patients intubated in the ED, orotracheal intubation was the first method attempted for 578 (>99%) and was successful on the first attempt for 515 of 578 (89%). Macintosh video laryngoscopy (88% of initial attempts) and a bougie (68% of initial attempts) were commonly used adjuncts. For 345 of 578 patients (60%), the laryngeal tube was removed before intubation attempts. For 112 of 578 patients (19%), the first intubation attempt occurred with the deflated laryngeal tube left in place. Three patients (<1%) required a surgical airway. CONCLUSION In this cohort, emergency physicians successfully exchanged an out-of-hospital laryngeal tube for an endotracheal tube, using commonly available airway management techniques. ED clinicians should be familiar with techniques for exchanging out-of-hospital extraglottic airways for an endotracheal tube.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | | | - Gabriella B Horton
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Darren A Braude
- Departments of Emergency Medicine and Anesthesiology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
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Miller KA, Monuteaux MC, Aftab S, Lynn A, Hillier D, Nagler J. A Randomized Controlled Trial of a Video-Enhanced Advanced Airway Curriculum for Pediatric Residents. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:1858-1864. [PMID: 30095451 DOI: 10.1097/acm.0000000000002392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE Pediatric advanced airway management is a low-frequency but critical procedure, making it challenging for trainees to learn. This study examined the impact of a curriculum integrating prerecorded videos of patient endotracheal intubations on performance related to simulated pediatric intubation. METHOD The authors conducted a randomized controlled educational trial for pediatric residents between January 2015 and June 2016 at Boston Children's Hospital. Investigators collecting data were blinded to the intervention. The control group received a standard didactic curriculum including still images, followed by simulation on airway trainers. The intervention group received a video-enhanced didactic curriculum including deidentified intubation clips recorded using a videolaryngoscope, followed by simulation. The study assessed intubation skills on simulated infant and pediatric airway scenarios of varying difficulty immediately after instruction and at three months. RESULTS Forty-nine trainees completed the curriculum: 23 received the video-enhanced curriculum and 26 received the standard curriculum. Median time to successful intubation was 18.5 and 22 seconds in the video-enhanced and standard groups, respectively. Controlling for mannequin age and difficulty, residents receiving the video-enhanced curriculum successfully intubated faster (hazard ratio [95% confidence interval]: 1.65 [1.25, 2.19]). Video-enhanced curriculum participants also demonstrated decreased odds of requiring multiple attempts and of esophageal intubation. At three-month follow-up, residents who received the video-enhanced curriculum remained faster at intubation (hazard ratio [95% confidence interval]: 1.93 [1.23, 3.02]). CONCLUSIONS Integrating videos of patient intubations into an airway management curriculum improved participating pediatric residents' intubation performance on airway trainers with sustained improvement at three months.
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Affiliation(s)
- Kelsey A Miller
- K.A. Miller is a fellow, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts. M.C. Monuteaux is senior epidemiologist and biostatistician, Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts. S. Aftab is director, Fetal Care Center, Nicklaus Children's Hospital, Miami, Florida. A. Lynn is a medical student, Midwestern University Arizona College of Osteopathic Medicine, Glendale, Arizona. D. Hillier is staff physician, Intermediate Care Program, Boston Children's Hospital, Boston, Massachusetts. J. Nagler is associate physician, Division of Emergency Medicine, and director, Pediatric Emergency Medicine Fellowship, Boston Children's Hospital, Boston, Massachusetts
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Vukovic AA, Hanson HR, Murphy SL, Mercurio D, Sheedy CA, Arnold DH. Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department. Am J Emerg Med 2018; 37:27-32. [PMID: 29699900 DOI: 10.1016/j.ajem.2018.04.039] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted. OBJECTIVE Determine association between AO and hypoxemia in pediatric patients undergoing ETI. METHODS Observational study at an urban, tertiary children's hospital emergency department. Pediatric patients undergoing ETI were examined during eras without (January 2011-June 2011) and with (August 2014-March 2017) apneic oxygenation. The primary outcome was hypoxemia, defined as pulse oximetry (SpO2) < 90%. The χ2 and Wilcoxon rank-sum tests examined differences between cohorts. Multivariable regression models examined adjusted associations between covariates and hypoxemia. RESULTS 149 patients were included. Cohorts were similar except for greater incidence of altered mental status in those receiving AO (26% vs. 7%, p = 0.03). Nearly 50% of the pre-AO cohort experienced hypoxemia during ETI, versus <25% in the AO cohort. Median [IQR] lowest SpO2 during ETI was 93 (69, 99) for pre-AO and 100 [95, 100] for the AO cohort (p < 0.001). In a multivariable logistic regression model, hypoxemia during ETI was associated with AO (aOR 0.3, 95% confidence interval [CI] 0.1-0.8), increased age (for 1 year, aOR 0.8, 95% CI 0.7-1.0), lowest SpO2 before ETI (for 1% increase, aOR 0.9, 95% CI 0.8-1.0), and each additional intubation attempt (aOR 4.0, 95% CI 2.2-7.2). CONCLUSIONS Apneic oxygenation is an easily-applied intervention associated with decreases in hypoxemia during pediatric ETI. Nearly 50% of children not receiving AO experienced hypoxemia.
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Affiliation(s)
- Adam A Vukovic
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA.
| | - Holly R Hanson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - Shelley L Murphy
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - Danielle Mercurio
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA
| | - Craig A Sheedy
- Department of Emergency Medicine, Vanderbilt University Medical Center, 1313 21st Avenue South, 703 Oxford House, Nashville, TN 37232, USA
| | - Donald H Arnold
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Vanderbilt University Medical Center, 2200 Children's Way Suite 1025, Nashville, TN 37232, USA; Department of Pediatrics, Division of Pulmonary Medicine and the Center for Asthma Research Vanderbilt University School of Medicine, 2200 Children's Way, Nashville, TN 37232, USA
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Abstract
OBJECTIVES Intubation in critically ill pediatric patients is associated with approximately 20% rate of adverse events, but rates in the high-risk condition of sepsis are unknown. Our objectives were to describe the frequency and characteristics of tracheal intubation adverse events in pediatric sepsis. DESIGN Retrospective cohort study of a sepsis registry. SETTING Two tertiary care academic emergency departments and four affiliated urgent cares within a single children's hospital health system. PATIENTS Children 60 days and older to 18 years and younger who required nonelective intubation within 24 hours of emergency department arrival. Exclusion criteria included elective intubation, intubation prior to emergency department arrival, presence of tracheostomy, or missing intubation chart data. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS The outcome was tracheal intubation adverse event as defined by the National Emergency Airway Registry Tool 4 KIDS. During the study period, 118 of 2,395 registry patients met inclusion criteria; 100% of intubations were successful. First attempt success rate was 57% (95% CI, 48-65%); 59% were intubated in the emergency department, and 28% were intubated in the PICU. First attempts were by a resident (30%), a fellow (42%), attending (6%), and anesthesiologist (13%). Tracheal intubation adverse events were reported in 61 (43%; 95% 43-61%) intubations with severe tracheal intubation adverse events in 22 (17%; 95 CI, 13-27%) intubations. Hypotension was the most common severe event (n = 20 [17%]) with 14 novel occurrences during intubation. Mainstem bronchial intubation was the most common nonsevere event (n = 28 [24%]). Residents, advanced practice providers, and general pediatricians in urgent care settings had the lowest rates of first-pass success. CONCLUSIONS The rates of tracheal intubation adverse events in this study are higher than in nonelective pediatric intubations in all conditions and highlight the high-risk nature of intubations in pediatric sepsis. Further research is needed to identify optimal practices for intubation in pediatric sepsis.
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Kerrey BT, Rinderknecht A, Mittiga M. High Risk, Low Frequency: Optimizing Performance of Emergency Intubation for Children. Ann Emerg Med 2017; 70:783-786. [DOI: 10.1016/j.annemergmed.2017.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Indexed: 10/19/2022]
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Rinderknecht AS, Dyas JR, Kerrey BT, Geis GL, Ho MH, Mittiga MR. Studying the Safety and Performance of Rapid Sequence Intubation: Data Collection Method Matters. Acad Emerg Med 2017; 24:411-421. [PMID: 27976450 DOI: 10.1111/acem.13145] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 11/21/2016] [Accepted: 11/29/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We sought to describe and compare chart and video review as data collection sources for the study of emergency department (ED) rapid sequence intubation (RSI). METHODS This retrospective cohort study compares the availability and content of key RSI outcome and process data from two sources: chart and video data from 12 months of pediatric ED RSI. Key outcomes included adverse effects (oxyhemoglobin desaturation, physiologic changes, inadequate paralysis, vomiting), process components (number of laryngoscopy attempts, end-tidal CO2 detection), and timing data (duration of preoxygenation and laryngoscopy attempts). RESULTS We reviewed 566 documents from 114 cases with video data. Video review detected higher rates of adverse effects (67%) than did chart review (46%, p < 0.0001), identifying almost twice the rate of desaturation noted in the chart (34% vs. 18%, p = 0.0002). The performance and timing of key RSI processes were significantly more reliably available via video review (timing and duration of preoxygenation, as well as timing, duration, and number of laryngoscopy attempts, all p < 0.05). Video review identified 221 laryngoscopy attempts, whereas chart review only identified 187. CONCLUSIONS When compared with video review for retrospective study of RSI in a pediatric ED, chart review significantly underestimated adverse effects, inconsistently contained data on important RSI process elements, rarely provided time data, and often conflicted with observations made on video review. Interpretation of and design of future studies of RSI should take into consideration the quality of the data source.
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Affiliation(s)
- Andrea S. Rinderknecht
- Department of Pediatrics; Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
- University of Cincinnati College of Medicine; Cincinnati OH
| | - Jenna R. Dyas
- Department of Pediatrics; Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Benjamin T. Kerrey
- Department of Pediatrics; Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
- University of Cincinnati College of Medicine; Cincinnati OH
| | - Gary L. Geis
- Department of Pediatrics; Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
- University of Cincinnati College of Medicine; Cincinnati OH
| | - Mona H. Ho
- Department of Pediatrics; Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Matthew R. Mittiga
- Department of Pediatrics; Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
- University of Cincinnati College of Medicine; Cincinnati OH
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Wu G, Wollen A, Himley S, Austin G, Delarosa J, Izadnegahdar R, Ginsburg AS, Zehrung D. A model for oxygen conservation associated with titration during pediatric oxygen therapy. PLoS One 2017; 12:e0171530. [PMID: 28234903 PMCID: PMC5325194 DOI: 10.1371/journal.pone.0171530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 01/23/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Continuous oxygen treatment is essential for managing children with hypoxemia, but access to oxygen in low-resource countries remains problematic. Given the high burden of pneumonia in these countries and the fact that flow can be gradually reduced as therapy progresses, oxygen conservation through routine titration warrants exploration. AIM To determine the amount of oxygen saved via titration during oxygen therapy for children with hypoxemic pneumonia. METHODS Based on published clinical data, we developed a model of oxygen flow rates needed to manage hypoxemia, assuming recommended flow rate at start of therapy, and comparing total oxygen used with routine titration every 3 minutes or once every 24 hours versus no titration. RESULTS Titration every 3 minutes or every 24 hours provided oxygen savings estimated at 11.7% ± 5.1% and 8.1% ± 5.1% (average ± standard error of the mean, n = 3), respectively. For every 100 patients, 44 or 30 kiloliters would be saved-equivalent to 733 or 500 hours at 1 liter per minute. CONCLUSIONS Ongoing titration can conserve oxygen, even performed once-daily. While clinical validation is necessary, these findings could provide incentive for the routine use of pulse oximeters for patient management, as well as further development of automated systems.
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Affiliation(s)
- Grace Wu
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, United States of America
- Consultant for PATH, Seattle, Washington, United States of America
| | - Alec Wollen
- PATH, Seattle, Washington, United States of America
| | - Stephen Himley
- Consultant for PATH, Seattle, Washington, United States of America
| | - Glenn Austin
- PATH, Seattle, Washington, United States of America
| | | | - Rasa Izadnegahdar
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
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Driver BE, McGill JW. Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations. Ann Emerg Med 2017; 69:635-639. [PMID: 28110989 DOI: 10.1016/j.annemergmed.2016.11.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/29/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
Abstract
STUDY OBJECTIVE Angioedema is an uncommon but important cause of airway obstruction. Emergency airway management of angioedema is difficult. We seek to describe the course and outcomes of emergency airway management for severe angioedema in our institution. METHODS We performed a retrospective, observational study of all intubations for angioedema performed in an urban academic emergency department (ED) between November 2007 and June 2015. We performed a structured review of video recordings of each intubation. We identified the methods of airway management, the success of each method, and the outcomes and complications of the effort. RESULTS We identified 52 patients with angioedema who were intubated in the ED; 7 were excluded because of missing videos, leaving 45 patients in the analysis. Median time from arrival to the ED to the first intubation attempt was 33 minutes (interquartile range 17 to 79 minutes). Nasotracheal intubation was the most common first method (33/45; 73%), followed by video laryngoscopy (7/45; 16%). Two patients required attempts at more invasive airway procedures (retrograde intubation and cricothyrotomy). The intubating laryngeal mask airway was used as a rescue method 5 times after failure of multiple methods, with successful oxygenation, ventilation, and intubation through the laryngeal mask airway in all 5 patients. All patients were successfully intubated. CONCLUSION In this series of ED patients who were intubated because of angioedema, emergency physicians used a range of methods to successfully manage the airway. These observations provide key lessons for the emergency airway management of these critical patients.
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Affiliation(s)
- Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | - John W McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
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Eisenberg MA, Green-Hopkins I, Werner H, Nagler J. Comparison Between Direct and Video-assisted Laryngoscopy for Intubations in a Pediatric Emergency Department. Acad Emerg Med 2016; 23:870-7. [PMID: 27208690 DOI: 10.1111/acem.13015] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 05/13/2016] [Accepted: 05/18/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The objective was to compare video-assisted laryngoscopy (VAL) to direct laryngoscopy (DL) on success rate and complication rate of intubations performed in a pediatric emergency department (ED). METHODS This is a retrospective cohort study of attempted intubations of children aged 0-18 years in a pediatric ED between 2004 and 2014 with first attempt by an ED provider. In VAL, the laryngoscopist attempts direct visualization of the glottis with a C-MAC video laryngoscope while the video monitor is used for real-time guidance by a supervisor, back-up visualization for the laryngoscopist should the direct view be inadequate, and confirmation of endotracheal tube passage through the vocal cords. We performed univariate comparisons of intubations using DL to intubations using VAL on rates of first-pass success, complications, and whether the patient was successfully intubated by an ED provider. We then created a logistic regression model to adjust for provider experience level, difficult airway characteristics, and indications for intubation to compare intubations using DL to intubations using VAL for each outcome. RESULTS We identified 452 endotracheal intubations of 422 unique patients, of which 445 intubations had a first attempt by an ED provider. Six intubations were excluded due to insufficient information available in the record. Of the included intubations, 240 (55%) were attempted with DL and 199 (45%) with VAL. The overall first-pass success rate was 71% in the DL group and 72% in the VAL group. After adjustment for covariates, the first-pass success rate was similar between laryngoscopy approaches (adjusted odds ratio = 1.23, 95% confidence interval = 0.78 to 1.94). CONCLUSIONS We found no difference between DL and VAL with regard to first-pass intubation success rate, complication rate, or rate of successful intubation by ED providers for children undergoing intubation in a pediatric ED.
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Affiliation(s)
- Matthew A. Eisenberg
- Division of Emergency Medicine; Boston Children's Hospital; Harvard Medical School; Boston MA
| | - Israel Green-Hopkins
- Division of Emergency Medicine; Boston Children's Hospital; Harvard Medical School; Boston MA
| | - Heidi Werner
- Division of Pediatric Emergency Medicine; Boston Medical Center; Boston University School of Medicine; Boston MA
| | - Joshua Nagler
- Division of Emergency Medicine; Boston Children's Hospital; Harvard Medical School; Boston MA
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Delayed sequence intubation with ketamine in 2 critically ill children. Am J Emerg Med 2016; 34:1190.e1-2. [DOI: 10.1016/j.ajem.2015.11.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 11/17/2015] [Indexed: 12/20/2022] Open
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Donoghue A, Hsieh TC, Nishisaki A, Myers S. Tracheal intubation during pediatric cardiopulmonary resuscitation: A videography-based assessment in an emergency department resuscitation room. Resuscitation 2015; 99:38-43. [PMID: 26703462 DOI: 10.1016/j.resuscitation.2015.11.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/12/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe procedural characteristics of tracheal intubation (TI) during cardiopulmonary resuscitation (CPR) in a pediatric emergency department, and to characterize interruptions in CPR associated with TI performance. METHODS Retrospective single center case series. Resuscitations in a pediatric ED are videorecorded for quality improvement. Children who underwent TI while receiving chest compressions were eligible for inclusion. Intubations done by methods other than direct laryngoscopy were excluded. Background data included patient age and training background of intubator. Data on intubation attempts (success, laryngoscopy time) and chest compressions (interruptions, duration of pauses) were collected. RESULTS Between December 2012 and February 2014, 32 patients had 59 TI attempts performed during CPR. Overall first attempt success at TI was 15/32 (47%); a median of 2 attempts were made per patient (range 1 to 4). Median laryngoscopy time was 47s (range 8-115s). 32/59 (54%) TI attempts had an associated interruption in CPR; the median interruption duration was 25s (range 3-64s). TI attempts without interruption in CPR were successful in 20/32 (63%) compared to 11/27 (41%) when CPR was paused (p=0.09). Laryngoscopy time was not significantly different between TI attempts with (47±21s) and without (47±26s; p=0.2) interruptions in compressions. 25/32 (78%) of pauses exceeded 10s in duration. CONCLUSIONS TI during pediatric CPR results in significant interruptions in chest compressions. Procedural outcomes were not significantly different between attempts with and without compressions paused. In children receiving CPR, TI should be performed without pausing chest compressions.
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Affiliation(s)
- Aaron Donoghue
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Simulation, Innovation, and Advanced Education, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Ting-Chang Hsieh
- Center for Simulation, Innovation, and Advanced Education, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Akira Nishisaki
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Center for Simulation, Innovation, and Advanced Education, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sage Myers
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Mittiga MR, Rinderknecht AS, Kerrey BT. A Modern and Practical Review of Rapid-Sequence Intubation in Pediatric Emergencies. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2015. [DOI: 10.1016/j.cpem.2015.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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