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Khanam D, Schoenfeld E, Ginsberg-Peltz J, Lutfy-Clayton L, Schoenfeld DA, Spirko B, Brown CA, Nishisaki A. First-Pass Success of Intubations Using Video Versus Direct Laryngoscopy in Children With Limited Neck Mobility. Pediatr Emerg Care 2024; 40:454-458. [PMID: 37751531 DOI: 10.1097/pec.0000000000003058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE It is not clear whether video laryngoscopy (VL) is associated with a higher first-pass success rate in pediatric patients with limited neck mobility when compared with direct laryngoscopy (DL). We sought to determine the association between the laryngoscopy method and first-pass success. METHODS In this retrospective cohort study, we examined intubation data extracted from 2 prospectively collected, multicenter, airway management safety databases (National Emergency Airway Registry and the National Emergency Airway Registry for children), obtained during the years 2013-2018 in the emergency department. Intubations were included if patients were aged younger than 18 and had limited neck mobility. We compared first-pass success rates for ED intubations that were performed using VL versus DL. We built a structural causal model to account for potential confounders such as age, disease category (medical or trauma condition), other difficult airway characteristics, use of sedatives/paralytics, and laryngoscopist training level. We also analyzed adverse events as a secondary outcome. RESULTS Of 34,239 intubations (19,071 in the National Emergency Airway Registry and 15,168 in the National Emergency Airway Registry for children), a total of 341 intubations (1.0%) met inclusion criteria; 168 were performed via VL and 173 were performed via DL. The median age of patients was 124 months (interquartile range, 48-204). There was no difference in first-pass success between VL and DL (79.8% vs 75.7%, P = 0.44). Video laryngoscopy was not associated with higher first-pass success (odds ratio, 1.11; 95% confidence interval 0.84-1.47, with DL as a comparator) when a structural causal model was used to account for confounders. There was no difference in the adverse events between VL and DL groups (13.7% vs 8.7%, P = 0.19). CONCLUSION In children with limited neck mobility receiving tracheal intubation in the ED, neither VL nor DL was associated with a higher first-pass success rate.
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Affiliation(s)
- Dilruba Khanam
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Elizabeth Schoenfeld
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Julien Ginsberg-Peltz
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Lucienne Lutfy-Clayton
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | | | - Blake Spirko
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
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MUW researcher of the month. Wien Klin Wochenschr 2024; 136:369-370. [PMID: 38842576 DOI: 10.1007/s00508-024-02387-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
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Gutierrez GA, Henry J, April MD, Long BJ, Schauer SG. A Market Assessment of Introducer Technology to Aid With Endotracheal Intubation. Mil Med 2024; 189:e54-e57. [PMID: 37279509 DOI: 10.1093/milmed/usad186] [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: 01/22/2023] [Revised: 04/14/2023] [Accepted: 05/09/2023] [Indexed: 06/08/2023] Open
Abstract
INTRODUCTION Endotracheal intubation is a potentially lifesaving procedure. Previously, data demonstrated that intubation remains the most performed airway intervention in the Role 1 setting. Additionally, deployed data demonstrate that casualties intubated in the prehospital setting have worse survival than those intubated in the emergency department setting. Technological solutions may improve intubation success in this setting. Certain intubation practices, including the use of endotracheal tube introducer bougies, facilitate intubation success especially in patients with difficult airways. We sought to determine the current state of the market for introducer devices. MATERIALS AND METHODS This market review utilized Google searches to find products for intubation. The search criteria aimed to identify any device ideal for intubation in the emergency setting. Device data retrieved included manufacturer, device, cost, and design descriptions. RESULTS We identified 12 introducer-variants on the market. Devices varied with regards to composition (latex, silicone, polyethylene, combination of several materials, etc.), tip shape, special features for ease of intubation (markings for depth and visibility, size, etc.), disposability/reuse capability, measurements, and prices. The cost of each device ranged from approximately $5 to $100. CONCLUSIONS We identified 12 introducer-variants on the market. Clinical studies are necessary to determine which devices may improve patient outcomes in the Role 1 setting.
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Affiliation(s)
- Gianna A Gutierrez
- University of the Incarnate Word-School of Medicine, San Antonio, TX 78209, USA
| | - Jevaughn Henry
- University of the Incarnate Word-School of Medicine, San Antonio, TX 78209, USA
| | - Michael D April
- 40th Forward Resuscitative Surgical Detachment, Fort Carson, CO 80902, USA
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Brit J Long
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Steven G Schauer
- Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
- Department of Emergency Medicine, Brooke Army Medical Center, JBSA Fort Sam Houston, TX 78234, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234, USA
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April MD, Driver B, Schauer SG, Carlson JN, Bridwell RE, Long B, Stang J, Farah S, De Lorenzo RA, Brown CA. Extraglottic device use is rare during emergency airway management: A National Emergency Airway Registry (NEAR) study. Am J Emerg Med 2023; 72:95-100. [PMID: 37506583 DOI: 10.1016/j.ajem.2023.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/24/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
INTRODUCTION Airway management is a critical component of the management of emergency department (ED) patients. The ED airway literature primarily focuses upon endotracheal intubation; relatively less is known about the ED use of extraglottic devices (EGDs). The goal of this study was to describe the frequency of use, success, and complications for EGDs among ED patients. METHODS The National Emergency Airway Registry (NEAR) is a prospective, multi-center, observational registry. It captures data on all ED patients at participating sites requiring airway management. Intubating clinicians entered all data into an online system as soon as practical after each encounter. We conducted a secondary analysis of these data for all ED encounters in which EGD placement occurred. We used descriptive statistics to characterize these encounters. RESULTS Of 19,071 patients undergoing intubation attempts, 56 (0.3%) underwent EGD placement. Of 25 participating sites, 13 reported no cases undergoing EGD placement; the median number of EGDs placed per site was 2 (interquartile range 1-2.5, range 1-31). Twenty-nine (54%) patients had either hypotension or hypoxia prior to the start of airway management. Clinicians reported anticipation of a difficult airway in 55% and at least one difficult airway characteristic in 93% of these patients. Forty-one encounters entailed placement of a laryngeal mask airway (LMA®) Fastrach™, 33 of whom underwent subsequent successful intubation through the EGD and 7 of whom underwent intubation by alternative methods. An additional 10 encounters utilized a standard LMA® device. Providers placed 34 (61%) EGDs during the first intubation attempt. Seventeen EGD patients (30%) experienced peri-procedure adverse events, including 14 (25%) experiencing hypoxemia. None of these patients expired due to failed airways. CONCLUSIONS EGD use was rare in this multi-center ED registry. EGD occurred predominantly in patients with difficult airway characteristics with favorable airway management outcomes. Clinicians should consider this emergency airway device for patients with a suspected difficult airway.
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Affiliation(s)
- Michael D April
- 14th Field Hospital, Fort Stewart, GA, United States of America; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
| | - Brian Driver
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; US Army Institute of Surgical Research, JBSA Fort Sam, Houston, TX, United States of America
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, United States of America
| | - Rachel E Bridwell
- Department of Emergency Medicine, Madigan Army Medical Center, Tacoma, WA, United States of America
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America; Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America
| | - Jamie Stang
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, MN, United States of America
| | - Subrina Farah
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Robert A De Lorenzo
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States of America
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America
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Miller M, Storey H, Andrew J, Christian E, Hayes-Bradley C. Out-of-Hospital Pediatric Video Laryngoscopy With an Adult Device: A Case Series Presented With a Contemporary Group Intubated With Direct Laryngoscopy. Pediatr Emerg Care 2023; 39:666-671. [PMID: 36790879 DOI: 10.1097/pec.0000000000002909] [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: 02/16/2023]
Abstract
OBJECTIVES After introducing an adult video laryngoscope (VL) in our physician-paramedic prehospital and retrieval medical service, our quality assurance process identified this blade being used during pediatric intubations. We present a case series of pediatric intubations using this oversized adult VL alongside a contemporaneous group of direct laryngoscopy (DL) intubations. METHODS We performed a retrospective review of intubated patients 15 years or younger in our electronic quality assurance registry from January 1, 2017, to December 31, 2020. Data collected were demographic details, intubation equipment, drug doses, the number of intubation attempts, and complications. Results are presented according to those intubated with C-MAC4 VL (Karl Storz) alongside age-appropriate DL sizes. RESULTS Ninety-nine pediatric patients were intubated, 67 (67%) by CMAC4 and 32 (33%) by DL. Video laryngoscopy had a first-attempt success rate of 96% and DL 91%. A Cormach and Lehane view 1 or 2 was found in 66 VL (99%) and 29 DL patients (91%). Desaturation was reported in two VL and 1 DL patient. CONCLUSIONS Adult VL became the most common method of intubation in patients older than 1 year during the study period. An adult C-MAC4 VL could be considered for clinicians who prefer VL when a pediatric VL is unavailable or as a second-line device if a pediatric VL is not present when intubating children older than 1 year.
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Affiliation(s)
| | - Heather Storey
- Department of Anaesthesia, Great Ormond Street Hospital, London, United Kingdom
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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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7
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Prekker ME, Bjorklund AR, Myers C, Harvey L, Horton GB, Goldstein J, Usher SC, Reardon RF, Robinson A, Strobel AM, Driver BE. The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children. Ann Emerg Med 2023; 81:667-676. [PMID: 36841658 DOI: 10.1016/j.annemergmed.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE Bougie use during emergency tracheal intubation has not been well studied in children. METHODS This was a 10-year observational study of pediatric intubations (<18 years of age) in the emergency department (ED) of an academic institution. Bougie training and use are standard in our ED, including for emergency medicine residents. Study data were collected by a combination of charts and video reviews. We compare first-attempt intubation success and procedural complications between pediatric patients with and without bougie use during tracheal intubation in the ED. In addition, we evaluate the independent association of bougie use with first-attempt intubation success using multivariable logistic regression. RESULTS We collected data on intubation success and bougie use for 195 pediatric patients over more than 10 years. On the first tracheal intubation attempt, a pediatric bougie was used in 126 patients (65%). Median patient age was 5 years (interquartile range 1.7 to 9) in the bougie group and 1.7 years (interquartile range 0.2 to 5) in the no bougie group. Intubation was successful on the first attempt in 72% of intubations with a bougie versus 78% without a bougie (absolute difference -6%, 95% confidence interval [CI] -19 to 6%); the adjusted odds of first-attempt success with a bougie were 0.54 (95% CI 0.24 to 1.19). A procedural complication occurred for 38% of patients in the bougie group versus 51% in the no bougie group (-13%, 95% CI -27% to 2%). Two neonates, one in each group, experienced a potential injury to the airway or lower respiratory tract. CONCLUSION In an academic ED where the bougie is commonly used, bougie use in children was not associated with procedural success or complications. Our study suggests that a randomized clinical trial is needed to determine the effect of bougie use during emergency pediatric intubation.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hennepin County Medical Center.
| | - Ashley R Bjorklund
- Division of Pediatric Critical Care, Department of Pediatrics, Hennepin County Medical Center, and the University of Minnesota, M Health Masonic Children's Hospital
| | - Carrie Myers
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Lauren Harvey
- Department of Emergency Medicine, Hennepin County Medical Center
| | | | - Jack Goldstein
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Sarah C Usher
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Aaron Robinson
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Ashley M Strobel
- Division of Emergency Medicine and Child Advocacy, Department of Pediatrics, University of Minnesota, M Health Masonic Children's Hospital, Minneapolis, MN
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center
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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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Variability in Pediatric Emergency Airway Management Laryngoscopy Modality: Clinical Equipoise or Unwarranted Clinical Variation? Ann Emerg Med 2023; 81:123-125. [PMID: 36336543 DOI: 10.1016/j.annemergmed.2022.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
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10
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A Randomized Study of Rigid Video Stylet versus Macintosh Laryngoscope for Double-Lumen Endobronchial Tube Intubation Assistance in Thoracoscopic Pulmonary Surgery. J Clin Med 2023; 12:jcm12020540. [PMID: 36675468 PMCID: PMC9865992 DOI: 10.3390/jcm12020540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Double-lumen endobronchial tube (DLT) intubation is more challenging than single-lumen tube intubation is, and the rigid video stylet (RVS) is one of the tools that has emerged to deal with this demanding intubation procedure. We evaluated whether the UE® RVS can shorten the DLT intubation time and improve the first-attempt intubation success rate compared with that of Macintosh laryngoscope (ML). A total of 130 participants scheduled to undergo thoracoscopic pulmonary surgeries were enrolled. They were randomized to receive either ML- or RVS-assisted DLT intubation. The primary outcomes were the intubation time and first-attempt intubation success rate. The secondary outcomes were the overall intubation success rate, mean arterial pressure, postoperative sore throat (POST), and postoperative hoarseness at 1 h and 24 h. Compared with the ML group, the intubation time was significantly shorter in the RVS group (p < 0.001; 30.82 ± 10.61 vs. 39.62 ± 6.54 s), however, the first-attempt success rate was significantly lower (p = 0.048; 83.08% vs. 95.16%). The POST at 1 h was less severe in the RVS group (p = 0.021). No significant differences were found for the other indicators. Among the patients with normal airways, the UE® RVS can achieve faster DLT intubation and decrease the severity of a POST at 1 h, although it was associated with a lower first-attempt intubation success rate.
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11
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Miller KA, Dechnik A, Miller AF, D'Ambrosi G, Monuteaux MC, Thomas PM, Kerrey BT, Neubrand TL, Goldman MP, Prieto MM, Wing R, Breuer RK, D'Mello J, Jakubowicz A, Nishisaki A, Nagler J. See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine. AEM EDUCATION AND TRAINING 2022; 6:e10830. [PMID: 36562026 PMCID: PMC9763969 DOI: 10.1002/aet2.10830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 06/17/2023]
Abstract
Background Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees. Methods This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods. Results There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods. Conclusions The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.
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Affiliation(s)
- Kelsey A. Miller
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Andzelika Dechnik
- Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Andrew F. Miller
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Gabrielle D'Ambrosi
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Michael C. Monuteaux
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
| | - Phillip M. Thomas
- Division of Emergency Medicine, Department of PediatricsCincinnati Children'sCincinnatiOhioUSA
| | - Benjamin T. Kerrey
- Division of Emergency Medicine, Department of PediatricsCincinnati Children'sCincinnatiOhioUSA
| | - Tara Lynn Neubrand
- Department of Pediatrics – Emergency MedicineChildren's Hospital ColoradoAuroraColoradoUSA
| | - Michael Paul Goldman
- Departments of Pediatrics and Emergency MedicineYale‐New Haven Children's HospitalNew HavenConnecticutUSA
| | - Monica M. Prieto
- Department of Pediatrics – Emergency MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Robyn Wing
- Department of Emergency Medicine – Pediatric Emergency MedicineHasbro Children's HospitalProvidenceRhode IslandUSA
| | - Ryan K. Breuer
- Department of Pediatrics – Pediatric Critical CareOishei Children's HospitalBuffaloNew YorkUSA
| | - Jenn D'Mello
- Department of PediatricsUniversity of CalgaryCalgary, AlbertaCaliforniaUnited States
| | - Andy Jakubowicz
- Department of Emergency MedicineWakeMedRaleighNorth CarolinaUSA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Joshua Nagler
- Division of Emergency Medicine, Department of PediatricsBoston Children's HospitalBostonMassachusettsUSA
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12
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Pacheco GS, Patanwala AE, Leetch AN, Mendelson JS, Hurst NB, Sakles JC. Intubation During Pediatric Cardiac Arrest in the Emergency Department Is Associated With Reduced First-Pass Success. Pediatr Emerg Care 2022; 38:e1271-e1276. [PMID: 35482505 DOI: 10.1097/pec.0000000000002592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Airway compromise and respiratory failure are leading causes of pediatric cardiac arrest making advanced airway management central to pediatric resuscitation. Previous literature has demonstrated that achieving first-pass success (FPS) is associated with fewer adverse events. In cardiac arrest for adult patients, increasing number of intubation attempts is associated with lower likelihood of return of spontaneous circulation (ROSC) and favorable neurologic outcome. There is limited evidence regarding advanced airway management for pediatric out-of-hospital cardiac arrest (OHCA) in the emergency department (ED). The purpose of this study was to compare FPS in pediatric OHCA and non-cardiac arrest patients in the ED. METHODS This is an analysis of pediatric intubations prospectively recorded into a continuous quality improvement database in an academic pediatric ED over a 12-year period. Between July 1, 2007, and June 30, 2019, physicians recorded all intubations performed in the pediatric ED. The database included patient demographics and detailed information about each intubation such as age of the patient, reason for intubation, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation in the ED were eligible for inclusion in the study. The primary outcome was FPS for pediatric patients in cardiac arrest compared with those not in cardiac arrest. A logistic regressions analysis was performed to identify characteristics associated with FPS in OHCA patients. RESULTS Six hundred eight pediatric patients were intubated during the study period. One hundred three pediatric patients had OHCA compared with 459 non-cardiac arrest patients who underwent rapid sequence intubation. In patients with OHCA, 47.6% had FPS (95% confidence interval [CI], 38.2%-57.1%), 33% required 2 attempts (95% CI, 24.7%-42.6%), and 19.4% required 3 or more attempts (95% CI, 12.9%-28.2%). In patients without OHCA, 75.4% had FPS (95% CI, 75.4%-79.1%), 15% required 2 attempts (95% CI, 12.0%-18.6%), and 9.6% required 3 or more attempts (95% CI, 7.2%-12.6%). Cardiac arrest was associated with a reduction in FPS adjusted odds ratio 0.44 (95% CI, 0.26-0.77). CONCLUSIONS In this study, we found that pediatric OHCA is associated with reduced FPS in the ED. Although additional studies are needed, rescuers should prioritize restoring effective oxygenation and ventilation and optimizing intubation conditions before an advanced airway attempt.
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Affiliation(s)
| | - Asad E Patanwala
- University of Sydney School of Pharmacy Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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13
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Gan KH, Shepherd M. The adjuncts for endotracheal tube passage in simulated pediatric airways (AET‐SPA) study. J Am Coll Emerg Physicians Open 2022; 3:e12729. [PMID: 35505935 PMCID: PMC9051529 DOI: 10.1002/emp2.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives To investigate whether the use of adjuncts such as stylet, railroaded bougie, and preloaded bougie increases first‐pass success rate and decreases time to successful intubation when intubating simulated infant airways using direct laryngoscopy. Methods A crossover study using experienced practitioners (who were required to carry out emergency pediatric intubations as part of their usual practice) was completed. Participants completed a random sequence of 4 intubations in simulated “easy” airways and 4 intubations in simulated “difficult” airways, using naked endotracheal tube, stylet, railroaded bougie, and preloaded bougie on standardized infant airway manikins. First‐pass success rates and times to successful intubations were measured. Results From June 1 to December 30, 2019, 109 participants performed a total of 872 intubation attempts. In the easy airway, both naked endotracheal tube (mean 96.3% [95% confidence interval 90.9%–99.0%]) and stylet (mean 98.2% [95% confidence interval 93.5%–99.8%]) had higher first‐pass success rates than railroaded bougie and preloaded bougie. In the difficult airway, stylet (mean 76.1% [95% confidence interval 67.0%–83.8%]) had the highest first‐pass success rate, followed by the naked endotracheal tube, and then both the railroaded bougie and preloaded bougie. Differences in first‐pass success rates were independent of the participants’ numbers of previous pediatric intubations. Conclusion Results of this simulation‐based study suggest that stylet should be used as the first attempt technique for infant intubations regardless of the presence or absence of predicted airway difficulty. This finding needs further validation using alternative models and in non‐simulation settings.
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Affiliation(s)
- Khang Hee Gan
- Department of Emergency Starship Children's Hospital Grafton Auckland New Zealand
| | - Mike Shepherd
- Department of Emergency Starship Children's Hospital Grafton Auckland New Zealand
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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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Dean P, Kerrey B. Video screen visualization patterns when using a video laryngoscope for tracheal intubation: A systematic review. J Am Coll Emerg Physicians Open 2022; 3:e12630. [PMID: 35028640 PMCID: PMC8738719 DOI: 10.1002/emp2.12630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Published studies of video laryngoscopes are often limited by the lack of a clear definition of video laryngoscopy (VL). We performed a systematic review to determine how often published studies of VL report on video screen visualization. METHODS We searched PubMed, EMBASE and Scopus for interventional and observational studies in which a video laryngoscope equipped with a standard geometry blade was used for tracheal intubation. We excluded simulation based studies. Our primary outcome was data on video laryngoscope screen visualization. Secondary outcomes were explicit methodology for screen visualization. RESULTS We screened 4838 unique studies and included 207 (120 interventional and 87 observational). Only 21 studies (10% of 207) included any data on video screen visualization by the proceduralist, 19 in a yes/no fashion only (ie, screened viewed or not) and 2 with detail beyond whether the screen was viewed or not. In 11 more studies, visualization patterns could be inferred based on screen availability and in 16 more studies, the methods section stated how screen visualization was expected to be performed without reporting data collection on how the proceduralist interacted with the video screen. Risk of bias was high in the majority of included studies. CONCLUSIONS Published studies of VL, including many clinical trials, rarely include data on video screen visualization. Given the nuances of using a video laryngoscope, this is a critical deficiency, which largely prevents us from knowing the treatment effect of using a video laryngoscope in clinical practice. Future studies of VL must address this deficiency.
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Affiliation(s)
- Preston Dean
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Benjamin Kerrey
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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16
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Dean P, Edmunds K, Shah A, Frey M, Zhang Y, Boyd S, Kerrey BT. Video Laryngoscope Screen Visualization and Tracheal Intubation Performance: A Video-Based Study in a Pediatric Emergency Department. Ann Emerg Med 2021; 79:323-332. [PMID: 34952729 DOI: 10.1016/j.annemergmed.2021.11.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/11/2021] [Accepted: 11/16/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Our study objectives were to describe patterns of video laryngoscope screen visualization during tracheal intubation in a pediatric emergency department (ED) and to determine their associations with procedural performance. METHODS We conducted a prospective, observational, video-based study of pediatric ED patients undergoing tracheal intubation with a standard geometry video laryngoscope (Storz C-MAC; Karl Storz, Tuttlingen, Germany). Our primary exposure was video screen visualization patterns, measured by the percentage of each attempt spent viewing the screen and the number of times the proceduralist changed their gaze between the patient and screen (gaze switches). Our primary outcome was first-pass success. We compared measures of screen visualization between successful and unsuccessful first attempts using a generalized linear mixed model. RESULTS From December 2019 to October 2021, we collected data on 153 patients. The first-pass success rate was 79.1%. Proceduralists viewed the video screen during 80.4% of attempts; the median percentage of each attempt spent viewing the video screen was 42.1% (interquartile range 8.7% to 65.5%). The median number of gaze switches per attempt was 3 (interquartile range 1 to 6, maximum 22). The percentage of each attempt spent viewing the video screen was not associated with success (adjusted odds ratio 1.00, 95% confidence interval 0.93 to 1.08); additional gaze switches were associated with a lower likelihood of success (adjusted odds ratio 0.80, 95% confidence interval 0.71 to 0.90). CONCLUSION We found wide variation in how proceduralists viewed the video laryngoscope screen during intubations in a pediatric ED. We illustrate the application of 2 objective screen visualization measures to quantify and understand how clinicians actually use video laryngoscopy.
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Affiliation(s)
- Preston Dean
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Katherine Edmunds
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Ashish Shah
- Division of Emergency Medicine, Rady Children's Hospital, San Diego, CA
| | - Mary Frey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Yin Zhang
- Division of Emergency Medicine, and the Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stephanie Boyd
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Benjamin T Kerrey
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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17
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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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18
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Saracoglu KT, Gunalp B, Çabaklı GT, Saracoglu A. Never-ending debate on pediatric airway: laryngoscopy, blades and approaches. J Clin Anesth 2021; 76:110562. [PMID: 34743954 DOI: 10.1016/j.jclinane.2021.110562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/12/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Kemal Tolga Saracoglu
- Department of Anesthesiology and Intensive Care, Health Sciences University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Buket Gunalp
- Department of Anesthesiology and Intensive Care, Health Sciences University, Kartal Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Gamze Tanırgan Çabaklı
- Department of Anesthesiology and Intensive Care, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey.
| | - Ayten Saracoglu
- Department of Anesthesiology and Intensive Care, Marmara University, Pendik Training and Research Hospital, Istanbul, Turkey.
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Grissom TE, Samet RE. The Anesthesiologist's Role in Teaching Airway Management to Nonanesthesiologists: Who, Where, and How. Adv Anesth 2021; 38:131-156. [PMID: 34106831 PMCID: PMC7534755 DOI: 10.1016/j.aan.2020.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, T1R77, 22 South Greene Street, Baltimore, MD 21201, USA
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20
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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21
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April MD, Arana A, Reynolds JC, Carlson JN, Davis WT, Schauer SG, Oliver JJ, Summers SM, Long B, Walls RM, Brown CA. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation 2021; 162:403-411. [PMID: 33684505 DOI: 10.1016/j.resuscitation.2021.02.039] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 01/21/2023]
Abstract
AIM To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. METHODS This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. RESULTS Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. CONCLUSIONS Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.
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Affiliation(s)
- Michael D April
- From the 40th Forward Resuscitative Surgical Detachment, 627th Hospital Center, Fort Carson, CO, USA; Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
| | - Allyson Arana
- United States Army Institute of Surgical Research, San Antonio, TX, USA
| | - Joshua C Reynolds
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Jestin N Carlson
- Department of Emergency Medicine, Saint Vincent Hospital, Allegheny Health Network, Erie, PA, USA
| | - William T Davis
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Steven G Schauer
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; United States Army Institute of Surgical Research, San Antonio, TX, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Joshua J Oliver
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, WA, USA
| | - Shane M Summers
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, Ryder Trauma Center, Miami, FL, USA
| | - Brit Long
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, TX, USA
| | - Ron M Walls
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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22
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Miller KA, Marchese A, Luff D, Nagler J. Conceptualizing intubation sharing: A descriptive qualitative study of videolaryngoscopy for pediatric emergency airway management. AEM EDUCATION AND TRAINING 2021; 5:e10589. [PMID: 33842814 PMCID: PMC8019533 DOI: 10.1002/aet2.10589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/31/2021] [Accepted: 02/23/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND This study characterizes clinical and educational practices around the use of videolaryngoscopy in pediatric emergency airway management through qualitative exploration. METHODS This is a descriptive qualitative study using semi-structured interviews of emergency medicine physicians. Physicians were selected by theoretical sampling from urban, tertiary care pediatric hospitals across the United States until theoretical data saturation was achieved. The study applied a constructivist grounded theory approach to data collection and analysis. Manual line-by-line coding of interview transcripts was used initially, then grouped into categories with constant comparative analysis to generate the final coding scheme organized by themes and subthemes. Finally, memo-writing and iterative analysis meetings explored relationships between themes and identified an interpretive model. RESULTS Theoretical saturation was achieved after 10 of the initial 12 interviews. Emerging from the data were six themes that describe the concept of intubation sharing: (1) Videolaryngoscopy encompasses multiple modalities that all provide a shared view and ability to record; (2) Airway experts and systems help realize the full potential of videolaryngoscopy; (3) Videolaryngoscopy can be a clinical, educational, quality assurance and research tool; (4) Some skills required for videolaryngoscopy are unique, while others overlap with direct laryngoscopy; (5) Videolaryngoscopy allows a coaching laryngoscopist to provide real-time guidance to the primary laryngoscopist from a shared view; (6) Videolaryngoscopy provides an opportunity for post-intubation coaching and feedback and shared learning from a single experience for the provider community. CONCLUSIONS Through this multicenter qualitative interview study, we derived the concept of intubation sharing through videolaryngoscopy for real-time and remote coaching, for both the primary laryngoscopist and the community of emergency medicine providers who intubate.
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Affiliation(s)
- Kelsey A Miller
- Division of Emergency Medicine at Boston Children's HospitalHarvard Medical SchoolBostonMAUSA
| | - Ashley Marchese
- Division of Emergency Medicine at Boston Children's HospitalHarvard Medical SchoolBostonMAUSA
| | - Donna Luff
- Department of Pediatrics at Boston Children’s HospitalHarvard Medical SchoolBostonMAUSA
| | - Joshua Nagler
- Division of Emergency Medicine at Boston Children's HospitalHarvard Medical SchoolBostonMAUSA
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23
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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24
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Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
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Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
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Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, Olomu PN, Zhang B, Sathyamoorthy M, Gonzalez A, Kanmanthreddy S, Gálvez JA, Franz AM, Peyton J, Park R, Kiss EE, Sommerfield D, Griffis H, Nishisaki A, von Ungern-Sternberg BS, Nadkarni VM, McGowan FX, Fiadjoe JE. First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet 2020; 396:1905-1913. [PMID: 33308472 DOI: 10.1016/s0140-6736(20)32532-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/26/2020] [Accepted: 10/08/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Orotracheal intubation of infants using direct laryngoscopy can be challenging. We aimed to investigate whether video laryngoscopy with a standard blade done by anaesthesia clinicians improves the first-attempt success rate of orotracheal intubation and reduces the risk of complications when compared with direct laryngoscopy. We hypothesised that the first-attempt success rate would be higher with video laryngoscopy than with direct laryngoscopy. METHODS In this multicentre, parallel group, randomised controlled trial, we recruited infants without difficult airways abnormalities requiring orotracheal intubation in operating theatres at four quaternary children's hospitals in the USA and one in Australia. We randomly assigned patients (1:1) to video laryngoscopy or direct laryngoscopy using random permuted blocks of size 2, 4, and 6, and stratified by site and clinician role. Guardians were masked to group assignment. The primary outcome was the proportion of infants with a successful first attempt at orotracheal intubation. Analysis (modified intention-to-treat [mITT] and per-protocol) used a generalised estimating equation model to account for clustering of patients treated by the same clinician and institution, and adjusted for gestational age, American Society of Anesthesiologists physical status, weight, clinician role, and institution. The trial is registered at ClinicalTrials.gov, NCT03396432. FINDINGS Between June 4, 2018, and Aug 19, 2019, 564 infants were randomly assigned: 282 (50%) to video laryngoscopy and 282 (50%) to direct laryngoscopy. The mean age of infants was 5·5 months (SD 3·3). 274 infants in the video laryngoscopy group and 278 infants in the direct laryngoscopy group were included in the mITT analysis. In the video laryngoscopy group, 254 (93%) infants were successfully intubated on the first attempt compared with 244 (88%) in the direct laryngoscopy group (adjusted absolute risk difference 5·5% [95% CI 0·7 to 10·3]; p=0·024). Severe complications occurred in four (2%) infants in the video laryngoscopy group compared with 15 (5%) in the direct laryngoscopy group (-3·7% [-6·5 to -0·9]; p=0·0087). Fewer oesophageal intubations occurred in the video laryngoscopy group (n=1 [<1%]) compared with in the direct laryngoscopy group (n=7 [3%]; -2·3 [-4·3 to -0·3]; p=0·028). INTERPRETATION Among anaesthetised infants, using video laryngoscopy with a standard blade improves the first-attempt success rate and reduces complications. FUNDING Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.
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Affiliation(s)
- Annery G Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital Boston, MA, USA
| | - Agnes I Hunyady
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Patrick N Olomu
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Health System of Texas, Dallas, TX, USA
| | - Bingqing Zhang
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Adolfo Gonzalez
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Health System of Texas, Dallas, TX, USA
| | - Siri Kanmanthreddy
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Jorge A Gálvez
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Amber M Franz
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - James Peyton
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital Boston, MA, USA
| | - Raymond Park
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston Children's Hospital Boston, MA, USA
| | - Edgar E Kiss
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children's Health System of Texas, Dallas, TX, USA
| | - David Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, University of Western Australia, Nedlands, WA, Australia
| | - Heather Griffis
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, University of Western Australia, Nedlands, WA, Australia
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Francis X McGowan
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John E Fiadjoe
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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26
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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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27
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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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28
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April MD, Arana A, Schauer SG, Davis WT, Oliver JJ, Fantegrossi A, Summers SM, Maddry JK, Walls RM, Brown CA. Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med 2020; 27:1106-1115. [PMID: 32592205 DOI: 10.1111/acem.14063] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/30/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. METHODS We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. RESULTS There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg. CONCLUSIONS Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.
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Affiliation(s)
- Michael D. April
- From the 4th Infantry Division 2nd Brigade Combat Team Fort Carson CO USA
- the Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda MD USA
| | - Allyson Arana
- the United States Army Institute of Surgical Research San Antonio TX USA
| | - Steven G. Schauer
- the Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda MD USA
- the United States Army Institute of Surgical Research San Antonio TX USA
- the Department of Emergency Medicine San Antonio Military Medical Center San Antonio TX USA
| | - William T. Davis
- the Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda MD USA
- the Department of Emergency Medicine San Antonio Military Medical Center San Antonio TX USA
| | - Joshua J. Oliver
- the Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda MD USA
- the Department of Emergency Medicine San Antonio Military Medical Center San Antonio TX USA
| | - Andrea Fantegrossi
- the Department of Emergency Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA USA
| | - Shane M. Summers
- the Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda MD USA
- and the Department of Emergency Medicine Ryder Trauma Center Miami FL USA
| | - Joseph K. Maddry
- the Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences Bethesda MD USA
- the United States Army Institute of Surgical Research San Antonio TX USA
- the Department of Emergency Medicine San Antonio Military Medical Center San Antonio TX USA
| | - Ron M. Walls
- the Department of Emergency Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA USA
| | - Calvin A. Brown
- the Department of Emergency Medicine Brigham and Women's Hospital and Harvard Medical School Boston MA USA
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29
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Long E, Barrett MJ, Peters C, Sabato S, Lockie F. Emergency intubation of children outside of the operating room. Paediatr Anaesth 2020; 30:319-330. [PMID: 31834647 DOI: 10.1111/pan.13784] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 12/02/2019] [Accepted: 12/06/2019] [Indexed: 12/19/2022]
Abstract
Intubation of children outside of the operating room is performed infrequently and is often associated with life-threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non-operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems-based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi-disciplinary team training in the technical and nontechnical aspects of non-operating room intubation, debrief post-real and simulated events, and regular audit of performance all reduce life-threatening intubation-related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient-centered care delivery.
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Parkville, Vic., Australia.,Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Vic., Australia
| | - Michael J Barrett
- Department of Emergency Medicine, Children's Health Ireland at Crumlin, Dublin, Ireland.,National Children's Research Centre, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Cheryl Peters
- Pediatric Anesthesiology and Intensive Care, British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Stefan Sabato
- Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Anaesthesia and Pain Management, The Royal Children's Hospital, Parkville, Vic., Australia
| | - Francis Lockie
- Paediatric Emergency Department, Womens and Childrens Hospital, Adelaide, SA, Australia.,South Australia Ambulance Service MedSTAR Kids Emergency Retrieval, Adelaide, SA, Australia
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