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Wing R, Goldman MP, Prieto MM, Miller KA, Baluyot M, Tay KY, Bharath A, Patel D, Greenwald E, Larsen EP, Polikoff LA, Kerrey BT, Nishisaki A, Nagler J. Usability Testing Via Simulation: Optimizing the NEAR4PEM Preintubation Checklist With a Human Factors Approach. Pediatr Emerg Care 2024; 40:575-581. [PMID: 39078284 DOI: 10.1097/pec.0000000000003223] [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: 07/31/2024]
Abstract
OBJECTIVES To inform development of a preintubation checklist for pediatric emergency departments via multicenter usability testing of a prototype checklist. METHODS This was a prospective, mixed methods study across 7 sites in the National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM) collaborative. Pediatric emergency medicine attending physicians and senior fellows at each site were first oriented to a checklist prototype, including content previously identified using a modified Delphi approach. Each site used the checklist in 2 simulated cases: an "easy airway" and a "difficult airway" scenario. Facilitators recorded verbalization, completion, and timing of checklist items. After each simulation, participants completed an anonymous usability survey. Structured debriefings were used to gather additional feedback on checklist usability. Comments from the surveys and debriefing were qualitatively analyzed using a framework approach. Responses informed human factors-based optimization of the checklist. RESULTS Fifty-five pediatric emergency medicine physicians/fellows (4-13 per site) participated. Participants found the prototype checklist to be helpful, easy to use, clear, and of appropriate length. During the simulations, 93% of checklist items were verbalized and more than 80% were completed. Median time to checklist completion was 6.2 minutes (interquartile range, 4.8-7.1) for the first scenario and 4.2 minutes (interquartile range, 2.7-5.8) for the second. Survey and debriefing data identified the following strengths: facilitating a shared mental model, cognitively offloading the team leader, and prompting contingency planning. Suggestions for checklist improvement included clarifying specific items, providing more detailed prompts, and allowing institution-specific customization. Integration of these data with human factors heuristic inspection resulted in a final checklist. CONCLUSIONS Simulation-based, human factors usability testing of the National Emergency Airway Registry for Pediatric Emergency Medicine Preintubation Checklist allowed optimization prior to clinical implementation. Next steps involve integration into real-world settings utilizing rigorous implementation science strategies, with concurrent evaluation of the impact on patient outcomes and safety.
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Affiliation(s)
- Robyn Wing
- From the Division of Pediatric Emergency Medicine, Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University and Rhode Island Hospital/Hasbro Children's Hospital; Lifespan Medical Simulation Center, Providence, RI
| | - Michael P Goldman
- Departments of Pediatrics (Section of Pediatric Emergency Medicine) and Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Monica M Prieto
- Perelman School of Medicine at the University of Pennsylvania, Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kelsey A Miller
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Division of Pediatric Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Mariju Baluyot
- Departments of Pediatrics and Emergency Medicine, Indiana University School of Medicine, Divisions of Pediatric Emergency Medicine and Simulation, Riley Hospital for Children, Indianapolis, IN
| | - Khoon-Yen Tay
- Perelman School of Medicine at the University of Pennsylvania, Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anita Bharath
- Department of Emergency Medicine, Phoenix Children's, Phoenix, AZ
| | - Deepa Patel
- Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Division of Pediatric Emergency Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Emily Greenwald
- Department of Pediatrics, Duke Children's Hospital, Duke University Hospital, Durham, NC
| | - Ethan P Larsen
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Lee A Polikoff
- Division of Critical Care Medicine, Department of Pediatrics, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Benjamin T Kerrey
- University of Cincinnati, College of Medicine and the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Akira Nishisaki
- Department of Anesthesiology, Critical Care, and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Joshua Nagler
- Departments of Emergency Medicine and Pediatrics, Harvard Medical School, Division of Pediatric Emergency Medicine, Boston Children's Hospital, Boston, MA
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Shay R, Weikel BW, Mascorro M, Harding E, Beard L, Grover T, Barry JS. Continuous improvement of non-emergent neonatal intubations in a level IV NICU. J Perinatol 2024:10.1038/s41372-024-02062-7. [PMID: 39025954 DOI: 10.1038/s41372-024-02062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/05/2024] [Accepted: 07/11/2024] [Indexed: 07/20/2024]
Abstract
OBJECTIVE We sought to improve practices and outcomes related to non-emergent neonatal intubations in a level IV academic Neonatal Intensive Care Unit. STUDY DESIGN A multidisciplinary team created guidelines for non-emergent neonatal intubations. In period 1, premedication practices were standardized. In period 2, paralytic use and video laryngoscope use were recommended. Premedication and video laryngoscopy practices were assessed along with number of intubation attempts and frequency of bradycardia and desaturation. RESULTS 636 intubations performed by neonatology fellows and neonatal advanced practice providers were reviewed over six academic years. Two academic years were included in each of the following study periods: baseline, period 1, and period 2. In our unit, compliance with recommended premedication practices and administration of paralytic medication has increased considerably, and video laryngoscopy is now utilized in most of our procedures. The frequency of intubation success on the first attempt has increased, and the frequency of both bradycardia and desaturation during intubation has decreased. In our analysis, paralytic use (AOR 2.41, 95 CI (1.53, 3.81)) and the combination of paralytic and video laryngoscopy (AOR 4.07, 95 CI (2.09, 7.92)) are associated with increased odds of intubating successfully on the first attempt. CONCLUSIONS This initiative increased the use of standardized premedication, paralytic medication and video laryngoscopy for non-emergent neonatal intubations with temporally associated improvement in patient outcomes including fewer intubation attempts and reduction in physiologic instability.
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Affiliation(s)
- Rebecca Shay
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA.
| | - Blair W Weikel
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Melanie Mascorro
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Emma Harding
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Lauren Beard
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Theresa Grover
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - James S Barry
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA
- Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
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Wanous AA, Brown R, Rudser KD, Roberts KD. Comparison of laryngeal mask airway and endotracheal tube placement in neonates. J Perinatol 2024; 44:239-243. [PMID: 37919512 DOI: 10.1038/s41372-023-01818-x] [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] [Received: 07/03/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE We hypothesize that the time, number of attempts, and physiologic stability of placement of an LMA would be superior compared to ETT. STUDY DESIGN Videotape and physiologic parameters of LMA (n = 36) and ETT (n = 31) placement procedures for infants 28-36 weeks gestation were reviewed. RESULTS Duration of attempts (32 vs 66 s, p < 0.001) and mean total airway insertion time (88 vs 153 s, p = 0.06) was shorter for LMA compared to ETT. Mean number of attempts for successful placement was fewer for LMA (1.5 vs 1.9, p = 0.11). Physiologic parameters remained near baseline in both groups despite very different degrees of premedication. CONCLUSION Placement of an LMA required less time and fewer number of attempts compared to ETT. Physiologic stability of an LMA was maintained without the use of an analgesic and muscle relaxant. Use of an LMA is a favorable alternative to ETT placement for surfactant delivery in neonates. TRIAL REGISTRATION NCT01116921.
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Affiliation(s)
- Amanda A Wanous
- University of Minnesota Medical School, University of Minnesota, Minneapolis, MN, USA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Roland Brown
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Kyle D Rudser
- Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Kari D Roberts
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.
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Ali MA, Raju MP, Miller G, Vora N, Beeram M, Raju V, Shetty A, Govande V, Nguyen N, Chiruvolu A. Pre-Medications for Non-Emergency Tracheal Intubation in the United States Neonatal Intensive Care Units. Cureus 2024; 16:e53512. [PMID: 38440038 PMCID: PMC10911687 DOI: 10.7759/cureus.53512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Premedication in neonates undergoing elective intubation effectively minimizes the negative physiological events of bradycardia, systemic hypertension, intracranial hypertension, and hypoxia. Premedication decreases procedure-related pain and discomfort. This study aimed to evaluate the current practice of pre-intubation medications for non-emergent intubations in preterm and term neonates in the United States. STUDY DESIGN A cross-sectional survey (Appendix) was sent via e-mail to all level 3 and 4 Neonatal Intensive Care Units (NICUs) of the Organization of Neonatal Perinatal Medicine Training Program Directors (ONTPD), NICU directors with pediatric residency only, and Baylor Scott and White Health, Mednax, and Envision health services systems. RESULTS Of 170 responses, 41% (69/168) routinely premedicate, 38% (64/168) premedicate under specific circumstances, and 21% (35/168) do not administer any routine pre-intubation medications. Only 46% (77/168) of units had a written policy. The most frequently used drugs were fentanyl (68%, 116/170), atropine (39%, 66/170), midazolam (38%, 64/170), and morphine (26%, 45/170). 21% (36/170) used a two-drug combination, and 38% (64/170) used a three-drug combination. The most commonly used two-drug combination was atropine and fentanyl, and the most common three-drug combination was atropine, fentanyl, and a paralytic agent. CONCLUSION Despite the well-documented benefits of premedication for NICU intubations, as aligned with AAP recommendations, the US lags behind other nations, with stagnant rates since 2006. This disparity persists despite a rise in written policies, which exhibit significant content variations. The authors advocate for the adoption of standardized, AAP-aligned policies across all NICUs in the US. Continued research is vital to monitor the progress of this crucial practice and address any underlying barriers to implementation.
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Affiliation(s)
- Mahmoud A Ali
- Pediatrics/Neonatology, West Virginia University, Morgantown, USA
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Greg Miller
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Niraj Vora
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Venkata Raju
- Neonatology, Baylor Scott & White Health, Temple, USA
| | - Ashith Shetty
- Neonatology, Baylor Scott & White Health, Temple, USA
| | | | - Nguyen Nguyen
- Pediatrics, Baylor Scott & White Health, Temple, USA
| | - Arpitha Chiruvolu
- Neonatology, Baylor University Medical Center, Dallas, USA
- Neonatology, Pediatrix Medical Group, Dallas, USA
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Neches SK, DeMartino C, Shay R. Pharmacologic Adjuncts for Neonatal Tracheal Intubation: The Evidence Behind Premedication. Neoreviews 2023; 24:e783-e796. [PMID: 38036442 DOI: 10.1542/neo.24-12-e783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Premedication such as analgesia, sedation, vagolytics, and paralytics may improve neonatal tracheal intubation success, reduce intubation-associated adverse events, and create optimal conditions for performing this high-risk and challenging procedure. Although rapid sequence induction including a paralytic agent has been adopted for intubations in pediatric and adult critical care, neonatal clinical practice varies. This review aims to summarize details of common classes of neonatal intubation premedication including indications for use, medication route, dosage, potential adverse effects in term and preterm infants, and reversal agents. In addition, this review shares the literature on national and international practice variations; explores evidence in support of establishing premedication guidelines; and discusses unique circumstances in which premedication use has not been established, such as during catheter-based or minimally invasive surfactant delivery. With increasing survival of extremely preterm infants, clear guidance for premedication use in this population will be necessary, particularly considering potential short- and long-term side effects of procedural sedation on the developing brain.
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Affiliation(s)
- Sara K Neches
- Department of Pediatrics, Division of Neonatology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| | - Cassandra DeMartino
- Department of Pediatrics, Division of Neonatology, Yale New Haven Hospital, New Haven, CT
| | - Rebecca Shay
- Department of Pediatrics, Division of Neonatology, University of Colorado School of Medicine and Children's Hospital of Colorado, Denver, CO
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Pande CK, Stayer K, Rappold T, Alvin M, Koszela K, Kudchadkar SR. Comfort and Coordination among Interprofessional Care Providers Involved in Intubations in the Pediatric Intensive Care Unit. Crit Care Res Pract 2023; 2023:4504934. [PMID: 37829150 PMCID: PMC10567513 DOI: 10.1155/2023/4504934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/14/2023] [Accepted: 08/10/2023] [Indexed: 10/14/2023] Open
Abstract
Background Successful execution of invasive procedures in acute care settings, including tracheal intubation, requires careful coordination of an interprofessional team. The stress inherent to the intensive care unit (ICU) environment may threaten the optimal communication and planning necessary for the safe execution of this complex procedure. The objective of this study is to characterize the perceptions of interprofessional team members surrounding tracheal intubations in the pediatric ICU (PICU). Methods This is a single-center survey-based study of staff involved in the intubation of pediatric patients admitted to a tertiary level academic PICU. Physicians, nurses, and respiratory therapists (RT) involved in tracheal intubations were queried via standardized, discipline-specific electronic surveys regarding their involvement in procedural planning and overall awareness of and comfort with the intubation plan. Qualitative variables were assessed by both Likert scales and free-text comments that were grouped and analyzed thematically. Results One hundred and eleven intubation encounters were included during the study time period, of which 93 (84%) had survey responses from at least 2 professional teams. Among those included in the analysis, the survey was completed 244 times by members of the PICU teams including 86 responses from physicians, 76 from nurses, and 82 from RTs. Survey response rates were >80% from each provider team. There were significant differences in interprofessional team comfort with nurses feeling less well informed and comfortable with the intubation plan and process compared to physicians and RTs (p < 0.001 for both). Qualitative themes including clear communication, adequate planning and preparation prior to procedure initiation, and clear definition of roles emerged among both affirmative and constructive comments. Conclusions Exploration of provider perceptions and emergence of constructive themes expose opportunities for teamwork improvement strategies involving intubations in the PICU. The use of a preintubation checklist may improve organization and communication amongst team members, increase provider morale, decrease team stress levels, and, ultimately, may improve patient outcomes during this high stakes, coordinated event.
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Affiliation(s)
- Chetna K. Pande
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Kelsey Stayer
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Thomas Rappold
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Madeleine Alvin
- Department of Anesthesiology,Critical Care,and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Keri Koszela
- Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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7
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Herrick HM, O'Reilly MA, Foglia EE. Success rates and adverse events during neonatal intubation: Lessons learned from an international registry. Semin Fetal Neonatal Med 2023; 28:101482. [PMID: 38000925 PMCID: PMC10842734 DOI: 10.1016/j.siny.2023.101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Neonatal endotracheal intubation is a challenging procedure with suboptimal success and adverse event rates. Systematically tracking intubation outcomes is imperative to understand both universal and site-specific barriers to intubation success and safety. The National Emergency Airway Registry for Neonates (NEAR4NEOS) is an international registry designed to improve neonatal intubation practice and outcomes that includes over 17,000 intubations across 23 international sites as of 2023. Methods to improve intubation safety and success include appropriately matching the intubation provider and situation and increasing adoption of evidence-based practices such as muscle relaxant premedication and video laryngoscope, and potentially new interventions such as procedural oxygenation.
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Affiliation(s)
- Heidi M Herrick
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Mackenzie A O'Reilly
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, 2nd Floor, Philadelphia, PA, 19104, USA; Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin, 3400 Spruce St, PA, 19104, Philadelphia, Pennsylvania, USA.
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Pande CK, Stayer K, Rappold T, Alvin M, Koszela K, Kudchadkar SR. Is Provider Training Level Associated with First Pass Success of Endotracheal Intubation in the Pediatric Intensive Care Unit? J Pediatr Intensive Care 2023; 12:180-187. [PMID: 37565021 PMCID: PMC10411123 DOI: 10.1055/s-0041-1731024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/15/2021] [Indexed: 10/20/2022] Open
Abstract
Endotracheal intubation is a life-saving procedure in critically ill pediatric patients and a foundational skill for critical care trainees. Multiple intubation attempts are associated with increased adverse events and increased morbidity and mortality. Thus, we aimed to determine patient and provider factors associated with first pass success of endotracheal intubation in the pediatric intensive care unit (PICU). This prospective, single-center quality improvement study evaluated patient and provider factors associated with multiple intubation attempts in a tertiary care, academic, PICU from May 2017 to May 2018. The primary outcome was the number of tracheal intubation attempts. Predictive factors for first pass success were analyzed by using univariate and multivariable logistic regression analysis. A total of 98 intubation encounters in 75 patients were analyzed. Overall first pass success rate was 67% (66/98), and 7% (7/98) of encounters required three or more attempts. A Pediatric critical care medicine (PCCM) fellow was the first laryngoscopist in 94% (92/98) of encounters with a first pass success rate of 67% (62/92). Age of patient, history of difficult airway, provider training level, previous intubation experience, urgency of intubation, and time of day were not predictive of first pass success. First pass success improved slightly with increasing fellow year (fellow year = 1, 66%; fellow year = 2, 68%; fellow year = 3, 69%) but was not statistically significant. We identified no intrinsic or extrinsic factors associated with first pass intubation success. At a time when PCCM fellow intubation experience is at risk of declining, PCCM fellows should continue to take the first attempt at most intubations in the PICU.
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Affiliation(s)
- Chetna K. Pande
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Houston, Texas, United States
| | - Kelsey Stayer
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Thomas Rappold
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Madeleine Alvin
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Keri Koszela
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Sapna R. Kudchadkar
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
- Department of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
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Glenn T, Fischer L, Markowski A, Carr CB, Malay S, Hibbs AM. Complicated Intubations are Associated with Bronchopulmonary Dysplasia in Very Low Birth Weight Infants. Am J Perinatol 2023; 40:1245-1252. [PMID: 34500482 PMCID: PMC9239052 DOI: 10.1055/s-0041-1736130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association between desaturation <60% (severe desaturation) during intubation and a total number of intubation attempts in the first week of life in very low birth weight (VLBW) infants with adverse long-term outcomes including bronchopulmonary dysplasia (BPD) and severe periventricular/intraventricular hemorrhage grade 3 or 4 (PIVH). STUDY DESIGN A retrospective chart review was performed on VLBW infants intubated in the neonatal intensive care unit during the first week of life between January 2017 and July 2020. Descriptive tables were generated for two outcomes including BPD and PIVH. Multivariable logistic regression was performed for each outcome including significant predictors that differed between groups with a p-value of <0.2. RESULTS A total of 146 patients were included. Patients with BPD or PIVH had a lower gestational age, and patients with BPD had a lower BW. Patients with BPD had a greater number of intubation attempts in the first week of life (4 vs. 3, p < 0.001). In multivariable logistic regression controlling for confounding variables, the odds developing BPD were higher for patients with increased cumulative number of intubation attempts in the first week of life (odds ratio [OR]: 1.29, 95% confidence interval [CI]: 1.03-1.62, p = 0.029). Post hoc analyses revealed increased odds of developing BPD with increased number of intubation encounters in the first week of life (OR: 2.20, 95% CI: 1.04-4.82, p = 0.043). In this post hoc analysis including intubation encounters in the model; desaturation <60% during intubation in the first week of life was associated with increased odds of developing BPD (OR: 2.35, 95% CI: 1.02-5.63, p = 0.048). CONCLUSION The odds of developing BPD for VLBW infants were higher with increased intubation attempts and intubation encounters. In a post hoc analysis, the odds of developing BPD were also higher with desaturation during intubation. Further research is needed to determine mechanisms of the relationship between complicated intubations and the development of BPD. KEY POINTS · Neonatal intubations often require multiple attempts.. · Neonates frequently desaturate during intubation.. · Intubation attempts are positively associated with BPD.. · Severe desaturation may be positively associated with BPD..
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Affiliation(s)
- Tara Glenn
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Linnea Fischer
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ashley Markowski
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Cara Beth Carr
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Sindhoosha Malay
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Anna Maria Hibbs
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children’s Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
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Roberts K, Wanous A, Brown R, Rudser K. Comparison of Laryngeal Mask Airway and Endotracheal Tube Placement in Neonates. RESEARCH SQUARE 2023:rs.3.rs-3136331. [PMID: 37503152 PMCID: PMC10371080 DOI: 10.21203/rs.3.rs-3136331/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Objective We hypothesize that the time, number of attempts and physiologic stability of placement of an LMA would be superior compared to ETT. Study Design Videotape and physiologic parameters of LMA (n = 36) and ETT (n = 31) placement procedures for infants 28-36 weeks gestation were reviewed. Results Duration of attempts (32 vs 66 sec, p < 0.001) and mean total procedure time (88 vs 153 sec, p = 0.06) was shorter for LMA compared to ETT. Mean number of attempts for successful placement was fewer for LMA (1.5 vs 1.9, p = 0.11). Physiologic parameters remained near baseline in both groups despite very different degrees of premedication. Conclusion Placement of an LMA required less time and fewer number of attempts compared to ETT. Physiologic stability of an LMA was maintained without the use of an analgesic and muscle relaxant. Use of an LMA is a favorable alternative to ETT placement for surfactant delivery in neonates. Trial registration NCT01116921.
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11
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Miller KA, Prieto MM, Wing R, Goldman MP, Polikoff LA, Nishisaki A, Nagler J. Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach. Emerg Med J 2023; 40:287-292. [PMID: 36788006 DOI: 10.1136/emermed-2022-212758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 02/03/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Airway management checklists have improved paediatric patient safety in some clinical settings, but consensus on the appropriate components to include on a checklist for paediatric tracheal intubation in the ED is lacking. METHODS A multidisciplinary panel of 14 experts in airway management within and outside of paediatric emergency medicine participated in a modified Delphi approach to develop consensus on the appropriate components for a paediatric airway management checklist for the ED. Panel members reviewed, modified and added to the components from the National Emergency Airway Registry for Children airway safety checklist for paediatric intensive care units using a 9-point appropriateness scale. Components with a median score of 7.0-9.0 and a 25th percentile score ≥7.0 achieved consensus for inclusion. A priori, the modified Delphi method was limited to a maximum of two rounds for consensus on essential components and one additional round for checklist creation. RESULTS All experts participated in both rounds. Consensus was achieved on 22 components. Twelve were original candidate items and 10 were newly suggested or modified items. Consensus components included the following categories: patient assessment and plan (5 items), patient preparation (5 items), pharmacy (2 items), equipment (7 items) and personnel (3 items). The components were formatted into a 17-item clinically usable checklist. CONCLUSIONS Using the modified Delphi method, consensus was established among airway management experts around essential components for an airway management checklist intended for paediatric tracheal intubation in the ED.
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Affiliation(s)
- Kelsey A Miller
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Monica M Prieto
- Department of Pediatrics - Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robyn Wing
- Department of Emergency Medicine - Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Michael P Goldman
- Departments of Pediatrics and Emergency Medicine, Yale-New Haven Children's Hospital, New Haven, Connecticut, USA
| | - Lee A Polikoff
- Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joshua Nagler
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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12
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Pinheiro JMB, Munshi UK, Chowdhry R. Strategies to Improve Neonatal Intubation Safety by Preventing Endobronchial Placement of the Tracheal Tube-Literature Review and Experience at a Tertiary Center. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020361. [PMID: 36832490 PMCID: PMC9955846 DOI: 10.3390/children10020361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/30/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
Unintended endobronchial placement is a common complication of neonatal tracheal intubation and a threat to patient safety, but it has received little attention towards decreasing its incidence and mitigating associated harms. We report on the key aspects of a long-term project in which we applied principles of patient safety to design and implement safeguards and establish a safety culture, aiming to decrease the rate of deep intubation (beyond T3) in neonates to <10%. Results from 5745 consecutive intubations revealed a 47% incidence of deep tube placement at baseline, which decreased to 10-15% after initial interventions and remained in the 9-20% range for the past 15 years; concurrently, rates of deep intubation at referring institutions have remained high. Root cause analyses revealed multiple contributing factors, so countermeasures specifically aimed at improving intubation safety should be applied before, during, and immediately after tube insertion. Extensive literature review, concordant with our experience, suggests that pre-specifying the expected tube depth before intubation is the most effective and simple intervention, although further research is needed to establish accurate and accepted standards for estimating the expected depth. Presently, team training on intubation safety, plus possible technological advances, offer additional options for safer neonatal intubations.
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13
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Implementation of a Standardized Premedication Bundle to Improve Procedure Success for Nonemergent Neonatal Intubations. Pediatr Qual Saf 2022; 8:e622. [PMID: 36601630 PMCID: PMC9799173 DOI: 10.1097/pq9.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 11/30/2022] [Indexed: 01/06/2023] Open
Abstract
The American Academy of Pediatrics recommends premedication for all nonemergent neonatal intubations, yet there remains significant variation in this practice nationally. We aimed to standardize our unit's premedication practices for improved intubation success and reduced adverse events. Methods The study workgroup developed educational material and protocol content. Process measures included premedication use, education, and audit form completion. Primary (success on first intubation attempt and adverse event rates) and secondary (trainee success) study outcomes are displayed using statistical process control charts and pre-post cohort comparisons. Results Forty-seven percent (97/206) of nurses completed educational intervention before protocol release, with an additional 20% (42/206) following a staff reminder. Two hundred sixteen (216) patients were intubated per protocol with 81% (174/216) audit completion. Compared with baseline (n = 158), intubation attempts decreased from 2 (IQR, 1-2) to 1 (IQR, 1-2) (P = 0.03), and success on the first attempt increased from 40% (63/158) to 57% (124/216) (P < 0.01), with a notable improvement in trainee success from less than 1% (1/40) to 43% (31/72) (P < 0.01). The rate of severe and rare adverse events remained stable; however, there was a rise in nonsevere events from 30% (48/158) to 45% (98/216). The tachycardia rate increased with atropine use. There was no change in chest wall rigidity, number of infants unable to extubate following surfactant, or decompensation awaiting medications. Conclusions Standardizing procedural care delivery reduced intubation attempts and increased the attempt success rate. However, this was accompanied by an increase in the rate of nonsevere adverse events.
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14
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Foran J, Moore CM, Ni Chathasaigh CM, Moore S, Purna JR, Curley A. Nasal high-flow therapy to Optimise Stability during Intubation: the NOSI pilot trial. Arch Dis Child Fetal Neonatal Ed 2022; 108:244-249. [PMID: 36307187 PMCID: PMC10176365 DOI: 10.1136/archdischild-2022-324649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/04/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE In adult patients with acute respiratory failure, nasal high-flow (NHF) therapy at the time of intubation can decrease the duration of hypoxia. The objective of this pilot study was to calculate duration of peripheral oxygen saturation below 75% during single and multiple intubation attempts in order to inform development of a larger definitive trial. DESIGN AND SETTING This double-blinded randomised controlled pilot trial was conducted at a single, tertiary neonatal centre from October 2020 to October 2021. PARTICIPANTS Infants undergoing oral intubation in neonatal intensive care were included. Infants with upper airway anomalies were excluded. INTERVENTIONS Infants were randomly assigned (1:1) to have NHF 6 L/min, FiO2 1.0 or NHF 0 L/min (control) applied during intubation, stratified by gestational age (<34 weeks vs ≥34 weeks). MAIN OUTCOME MEASURES The primary outcome was duration of hypoxaemia of <75% up to the time of successful intubation, RESULTS: 43 infants were enrolled (26 <34 weeks and 17 ≥34 weeks) with 50 intubation episodes. In infants <34 weeks' gestation, median duration of SpO2 of <75% was 29 s (0-126 s) vs 43 s (0-132 s) (p=0.78, intervention vs control). Median duration of SpO2 of <75% in babies ≥34 weeks' gestation was 0 (0-32 s) vs 0 (0-20 s) (p=0.9, intervention vs control). CONCLUSION This pilot study showed that it is feasible to provide NHF during intubation attempts. No significant differences were noted in duration of oxygen saturation of <75% between groups; however, this trial was not powered to detect a difference. A larger, higher-powered blinded study is warranted.
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Affiliation(s)
- Jason Foran
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Carmel Maria Moore
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Caitriona M Ni Chathasaigh
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Shirley Moore
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Jyothsna R Purna
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Anna Curley
- Department of Neonatology, National Maternity Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
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15
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Volsko TA. Kittredge Lecture: Airway Safety in Neonatal and Pediatrics. Respir Care 2022; 67:756-768. [PMID: 35606005 PMCID: PMC9994189 DOI: 10.4187/respcare.10017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
During invasive ventilatory support, infants and children are inherently at risk for developing injury or complications related to the insertion and maintenance of an endotracheal tube (ETT). It is essential for respiratory therapists to understand the factors that contribute to the propensity for harm while preparing for, inserting, securing, and maintaining the position of an ETT throughout the duration of use. Implementing care bundles based on the available literature is useful in reducing iatrogenic complications as well as the risk for morbidity and mortality of pediatric patients requiring an ETT to facilitate respiratory support.
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Affiliation(s)
- Teresa A Volsko
- Department of Quality and Data Integration, The Centers, Cleveland, Ohio.
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16
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Cardiac arrest during endotracheal intubation of children with systolic dysfunction. Cardiol Young 2022; 33:532-538. [PMID: 35504840 DOI: 10.1017/s1047951122001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This multicenter study aimed to describe peri-intubation cardiac arrest in paediatric cardiac patients with significant (moderate or severe) systolic dysfunction of the systemic ventricle. Intubation data were collected from 4 paediatric cardiac ICUs in the United States (January 2015 - December 2017). Clinician practices during intubation of patients with significant dysfunction were compared to practices during intubation of patients without significant systolic dysfunction. There were 67 intubations in patients with significant systolic dysfunction. Peri-intubation cardiac arrest rate in this population was 14.9% (10/67); peri-intubation mortality was 3%. Majority (6/10; 60%) of the cardiac arrests were classified as pulseless electrical activity. Patients with cardiac arrest upon intubation had a higher serum lactate and lower serum pH than patients without peri-intubation cardiac arrest in the significant systolic dysfunction group.In comparing cardiac ICU patients with significant systolic dysfunction (n = 67) to patients from the same time period with normal ventricular function or mild dysfunction (n = 183), clinicians were less likely to use midazolam (11.9% versus 25.1%; p = 0.03) and more likely to use etomidate (16.4% versus 4.4%; p = 0.002) for intubation. Use of other sedative agents, video laryngoscopy, atropine, inotrope initiation, and consultation of an anaesthesiologist for intubation were not statistically different between the groups.This is the first study to describe the rate of and risk factors for peri-intubation cardiac arrest in paediatric cardiac ICU patients with systolic dysfunction. There was a higher peri-intubation cardiac arrest rate compared to published rates in critically ill children with heart disease and compared to children with significant systolic dysfunction undergoing elective general anaesthesia.
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Indications and outcomes of neonatal intubation: A single-center, prospective study in a middle-income country. Pediatr Neonatol 2022; 63:125-130. [PMID: 34716129 DOI: 10.1016/j.pedneo.2021.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/02/2021] [Accepted: 09/13/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND This study assessed the success rate and associated complications of hospital-wide neonatal endotracheal intubations by pediatric residents and neonatal fellows using direct laryngoscopy. Secondary objectives were to identify characteristics and indications for the procedure in a tertiary-care center. METHODS A cross-sectional observational study was conducted. We prospectively collected performance and infant outcome data after neonatal intubation between March 1, 2019 and February 29, 2020. RESULTS 171 intubations were observed in 105 infants. The median infant gestational age was 31.0 weeks (interquartile range [IQR]: 27.5-36.0 weeks). Fifty infants (48%) were very low birth weight (VLBW, <1500 g; median 1640 g [IQR: 870-2420 g]). The most common indication for intubation was respiratory failure (65%). Pediatric residents and neonatal fellows had overall success rates of 66% and 98%, respectively. The success rate for the first intubation attempt was higher with more advanced pediatric residency training (P < 0.001). The median attempts for each intubation were 1 (IQR: 1-2) for both VLBW and non-VLBW infants (P = 0.48). The adverse outcome rates were 5% and 3% for VLBW and non-VLBW infants, respectively (P = 0.53). More than 2 intubation attempts was the only significant independent risk factor for adverse outcomes (adjusted odds ratio 6.7; 95% CI 1.3-33.6; P = 0.02). CONCLUSIONS The success rate of pediatric residents for neonatal intubation was similar for VLBW and non-VLBW infants. The main indication was respiratory failure, and nearly half were infants with VLBW. To minimize adverse sequelae, written guidelines limiting the number of intubation attempts by junior trainees are warranted.
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18
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Dalrymple HM, Browning Carmo K. Improving Intubation Success in Pediatric and Neonatal Transport Using Simulation. Pediatr Emerg Care 2022; 38:e426-e430. [PMID: 33273427 DOI: 10.1097/pec.0000000000002315] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric and neonatal first-pass intubation rates are higher in adult trained retrieval services than in neonatal or pediatric trained services. Some authors have attributed this to more frequent opportunities to practice the skill in the adult population. OBJECTIVE The aim of this study was to increase the first-pass intubation rate without adverse events by introducing daily intubation simulation at our mixed neonatal and pediatric retrieval service. METHODS This prospective cohort study performed from July to December 2018 in our mixed neonatal and pediatric retrieval service involved 16 medical staff performing simulated intubation at commencement of their retrieval shift with a retrieval nurse. Checklists for neonatal and pediatric intubation were introduced to the retrieval service for the intervention cohort. Participants were asked to complete questionnaires about intubation performed on retrieval to gather data not routinely collected by the service. RESULTS Seven hundred and sixty-eight patients were retrieved by the service and 70 patients required intubation by the retrieval team during the intervention period. First-pass intubation rates were higher during the intervention period compared with a historical cohort, despite less intubations being performed overall. First-pass intubation rates improved from 59% to 78% in neonatal patients (P = 0.032), 58% to 65% in pediatric patients (P = 0.68) and from 58% to 74% overall (P = 0.043). There were no severe adverse events detected during the intervention period. Minor adverse events were associated with multiple attempts at intubation (P < 0.001). Overall compliance with simulation protocol was 43.5%, and on average, each doctor completed simulation once per month. CONCLUSIONS Simulation is a useful adjunct to support neonatal and pediatric intubation training in the current environment of reducing intubation frequency.
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19
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Shay R, Weikel BW, Grover T, Barry JS. Standardizing premedication for non-emergent neonatal tracheal intubations improves compliance and patient outcomes. J Perinatol 2022; 42:132-138. [PMID: 34584197 DOI: 10.1038/s41372-021-01215-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/26/2021] [Accepted: 09/10/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We sought to standardize and improve compliance with evidence-based premedication for non-emergent neonatal intubations in two academic-affiliated Neonatal Intensive Care Units. STUDY DESIGN A multidisciplinary team created guidelines and electronic medical record order sets for intubation. Compliance with recommended premedication, number of intubation attempts, and frequency of bradycardia and desaturation were assessed. RESULTS 387 intubation procedures were reviewed. Provision of recommended premedication increased by 36% and 75% at the level III and IV units, respectively. Decreased frequency of bradycardia during intubation (p = 0.0003) occurred in the level III unit. A reduction in number of intubation attempts (p ≤ 0.001), improvement in first-attempt intubation success (p ≤ 0.001), and decreased frequency of bradycardia (p = 0.01) and desaturation (p = 0.02) during intubation occurred in the level IV unit. CONCLUSIONS This quality improvement initiative improved standardized premedication compliance and decreased adverse events associated with non-emergent neonatal intubations in two separate units.
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Affiliation(s)
- Rebecca Shay
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA. .,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA.
| | - Blair W Weikel
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - Theresa Grover
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
| | - James S Barry
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO, USA.,Children's Hospital Colorado, Section of Neonatology, Aurora, CO, USA
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20
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Kothari R, Hodgson KA, Davis PG, Thio M, Manley BJ, O'Currain E. Time to desaturation in preterm infants undergoing endotracheal intubation. Arch Dis Child Fetal Neonatal Ed 2021; 106:603-607. [PMID: 33931396 PMCID: PMC8543201 DOI: 10.1136/archdischild-2020-319509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/13/2021] [Accepted: 03/23/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Neonatal endotracheal intubation is often associated with physiological instability. The Neonatal Resuscitation Program recommends a time-based limit (30 s) for intubation attempts in the delivery room, but there are limited physiological data to support recommendations in the neonatal intensive care unit (NICU). We aimed to determine the time to desaturation after ceasing spontaneous or assisted breathing in preterm infants undergoing elective endotracheal intubation in the NICU. METHODS Observational study at The Royal Women's Hospital, Melbourne. A secondary analysis was performed of video recordings of neonates ≤32 weeks' postmenstrual age undergoing elective intubation. Infants received premedication including atropine, a sedative and muscle relaxant. Apnoeic oxygenation time (AOT) was defined as the time from the last positive pressure or spontaneous breath until desaturation (SpO2 <90%). RESULTS Seventy-eight infants were included. The median (IQR) gestational age at birth was 27 (26-29) weeks and birth weight 946 (773-1216) g. All but five neonates desaturated to SpO2 <90% (73/78, 94%). The median (IQR) AOT was 22 (14-32) s. The median (IQR) time from ceasing positive pressure ventilation to desaturation <80% was 35 (24-44) s and to desaturation <60% was 56 (42-68) s. No episodes of bradycardia were seen. CONCLUSIONS This is the first study to report AOT in preterm infants. During intubation of preterm infants in the NICU, desaturation occurs quickly after cessation of positive pressure ventilation. These data are important for the development of clinical guidelines for neonatal intubation. TRIAL REGISTRATION NUMBER ACTRN12614000709640.
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Affiliation(s)
- Radhika Kothari
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Kate Alison Hodgson
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Marta Thio
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Parkville, Victoria, Australia,Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia,Murdoch Children’s Research Institute, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Eoin O'Currain
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Parkville, Victoria, Australia,University College Dublin–National University of Ireland, Dublin, Ireland,The National Maternity Hospital, Holles St, Dublin, Ireland
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21
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Herrick HM, Pouppirt N, Zedalis J, Cei B, Murphy S, Soorikian L, Matthews K, Nassar R, Napolitano N, Nishisaki A, Foglia EE, Ades A, Nawab U. Reducing Severe Tracheal Intubation Events Through an Individualized Airway Bundle. Pediatrics 2021; 148:peds.2020-035899. [PMID: 34526350 PMCID: PMC8628255 DOI: 10.1542/peds.2020-035899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Neonatal tracheal intubation (TI) is a high-risk procedure associated with adverse safety events. In our newborn and infant ICU, we measure adverse tracheal intubation-associated events (TIAEs) as part of our participation in National Emergency Airway Registry for Neonates, a neonatal airway registry. We aimed to decrease overall TIAEs by 10% in 12 months. METHODS A quality improvement team developed an individualized approach to intubation using an Airway Bundle (AB) for patients at risk for TI. Plan-do-study-act cycles included AB creation, simulation, unit roll out, interprofessional education, team competitions, and adjusting AB location. Outcome measure was monthly rate of TIAEs (overall and severe). Process measures were AB initiation, AB use at intubation, video laryngoscope (VL) use, and paralytic use. Balancing measure was inadvertent administration of TI premedication. We used statistical process control charts. RESULTS Data collection from November 2016 to August 2020 included 1182 intubations. Monthly intubations ranged from 12 to 41. Initial overall TIAE rate was 0.093 per intubation encounter, increased to 0.172, and then decreased to 0.089. System stability improved over time. Severe TIAE rate decreased from 0.047 to 0.016 in June 2019. AB initiation improved from 70% to 90%, and AB use at intubation improved from 18% to 55%. VL use improved from 86% to 97%. Paralytic use was 83% and did not change. The balancing measure of inadvertent TI medication administration occurred once. CONCLUSIONS We demonstrated a significant decrease in the rate of severe TIAEs through the implementation of an AB. Next steps include increasing use of AB at intubation.
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Affiliation(s)
- Heidi M. Herrick
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicole Pouppirt
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jacqueline Zedalis
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bridget Cei
- Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie Murphy
- Department of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Leane Soorikian
- Department of Respiratory Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kelle Matthews
- Department of Respiratory Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rula Nassar
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Division of Neonatology, Christiana Care Health System, Newark, Delaware
| | - Natalie Napolitano
- Department of Respiratory Therapy, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anne Ades
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ursula Nawab
- Division of Neonatology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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22
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Glenn T, Sudhakar S, Markowski A, Malay S, Hibbs AM. Patient characteristics associated with complications during neonatal intubations. Pediatr Pulmonol 2021; 56:2576-2582. [PMID: 33983688 PMCID: PMC8298275 DOI: 10.1002/ppul.25453] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/21/2021] [Accepted: 04/30/2021] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Complications of neonatal intubation are known to be increased with emergent intubations, increased number of attempts, unstable hemodynamics, or ventilation failure; and decreased with use of paralytic medication and videolaryngoscopy. Patient characteristics associated with complications are not well understood. DESIGN/METHODS A retrospective cohort study was performed of neonates who underwent intubation between January 2017 and June 2019. Patient characteristics of infants with and without complications were compared. Complications included common adverse events and abnormal vital sign changes occurring during intubation. RESULTS A total of 467 intubation encounters in 352 infants were included with median gestational age (GA) at birth of 29 weeks, postmenstrual age (PMA) 33 weeks at intubation, and median weight 1795 g. 41.5% of infants had complications and 58.5% of infants did not. Infants with complications compared to infants without had a median FiO2 of 0.50 versus 0.45 (p = .183), median GA at birth of 29 versus 31 weeks (p < .001), median PMA of 32 weeks versus 33.0 weeks (p = .352), median weight of 1540 g versus 1970g (p = .091), and median chronological age of 3 days versus 1 day (p = .001). Generalized Estimating Equations controlling for administration of paralytic indicated decreased complications in infants ≤21.5 days in chronological age (OR, 0.45; 95% CI, 0.30-0.69) and increased complications in infants ≤1565 g (OR, 1.52; 95% CI, 1.04-2.23). CONCLUSION Patient characteristics associated with an increased rate of complications included chronological age and weight. Further study is needed to reduce complications.
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Affiliation(s)
- Tara Glenn
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Shwetha Sudhakar
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ashley Markowski
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Sindhoosha Malay
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Anna Maria Hibbs
- Division of Neonatology, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA.,Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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23
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Tamire T, Garbessa B, Gebeyu G, Getachew L. Tracheal Intubation-related adverse events in pediatrics anesthesia in Ethiopia. Paediatr Anaesth 2021; 31:515-521. [PMID: 33506587 DOI: 10.1111/pan.14143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tracheal intubation is a common intervention for many pediatric surgical patients. Even though it can be lifesaving, it carries a risk of morbidity and even mortality. Evidence is lacking regarding the adverse events related to pediatric intubation in Ethiopia. This study is aimed to assess the scale of tracheal intubation-related adverse events with its associated factors in pediatrics surgical patients at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. METHODS An Institutional-based cross-sectional study was conducted on 310 pediatric surgical patients who underwent major surgery from December 30, 2019, to February 30, 2020. All pediatrics patients scheduled for surgery under general anesthesia in the study period were included in this study. Data with complete information were entered into Epi Info version 7 and exported to SPSS version 22 for analysis. Descriptive statistics, bivariate, and multivariable logistic regression were computed to identify factors associated with tracheal intubation-related adverse events. The level of statistical significance was declared at a P-value of less than .05. RESULT In this study, the overall incidence of tracheal intubation-related adverse events in pediatrics patients was 36.5%. Being a neonate (AOR = 4.13, 95% CI: 1.26-13.49), emergency surgery (AOR = 3.39, 95% CI: 1.41-8.13), difficult intubation (AOR, 4.08, 95% CI: 1.01-7.50), intubation without using premedication (AOR = 1.75, 95% CI: 1.45-10.83), intubation without using muscle relaxant (AOR = 1.81; 95% CI: 1.10-8.14), and tracheal intubation attempted more than three times (AOR = 3.92, 95% CI: 0.16-7.39) were identified as independent predictors of tracheal intubation-related adverse events. CONCLUSION AND RECOMMENDATIONS The incidence of tracheal intubation-related adverse events in pediatric surgical patients is high. Anesthesia professionals should be vigilant and have a preplanned strategy to avoid intubation-related adverse events, especially in high-risk patients. The use of difficult airway algorithms, oxygen saturation monitoring, and training in simulation room are very important strategies to help reduce patient harm.
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Affiliation(s)
- Tadese Tamire
- Department of Anaesthesia, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Bayisa Garbessa
- Department of Anesthesia, College of Health Sciences, Diredawa University, Dire Dawa, Ethiopia
| | - Geresu Gebeyu
- Department of Anesthesia, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Lemlem Getachew
- Department of Anesthesia, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Walter‐Nicolet E, Marchand‐Martin L, Guellec I, Biran V, Moktari M, Zana‐Taieb E, Magny J, Desfrère L, Waszak P, Boileau P, Chauvin G, Saint Blanquat L, Borrhomée S, Droutman S, Merhi M, Zupan V, Karoui L, Cimerman P, Carbajal R, Durrmeyer X. Premedication practices for neonatal tracheal intubation: Results from the EPIPPAIN 2 prospective cohort study and comparison with EPIPPAIN 1. PAEDIATRIC AND NEONATAL PAIN 2021; 3:46-58. [PMID: 35547594 PMCID: PMC8975199 DOI: 10.1002/pne2.12048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 11/25/2022]
Abstract
To describe the frequency and nature of premedication practices for neonatal tracheal intubation (TI) in 2011; to identify independent risk factors for the absence of premedication; to compare data with those from 2005 and to confront observed practices with current recommendations. Data concerning TI performed in neonates during the first 14 days of their admission to participating neonatal/pediatric intensive care units were prospectively collected at the bedside. This study was part of the Epidemiology of Procedural Pain in Neonates study (EPIPPAIN 2) conducted in 16 tertiary care units in the region of Paris, France, in 2011. Multivariate analysis was used to identify factors associated with premedication use and multilevel analysis to identify center effect. Results were compared with those of the EPIPPAIN 1 study, conducted in 2005 with a similar design, and to a current guidance for the clinician for this procedure. One hundred and twenty‐one intubations carried out in 121 patients were analyzed. The specific premedication rate was 47% and drugs used included mainly propofol (26%), sufentanil (24%), and ketamine (12%). Three factors were associated with the use of a specific premedication: nonemergent TI (Odds ratio (OR) [95% CI]: 5.3 [1.49‐20.80]), existence of a specific written protocol in the ward (OR [95% CI]:4.80 [2.12‐11.57]), and the absence of a nonspecific concurrent analgesia infusion before TI (OR [95% CI]: 3.41 [1.46‐8.45]). No center effect was observed. The specific premedication rate was lower than the 56% rate observed in 2005. The drugs used were more homogenous and consistent with the current recommendations than in 2005, especially in centers with a specific written protocol. Premedication use prior to neonatal TI was low, even for nonemergent procedures. Scientific consensus, implementation of international or national recommendations, and local written protocols are urgently needed to improve premedication practices for neonatal intubation.
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Affiliation(s)
- Elizabeth Walter‐Nicolet
- Medicine and Neonatal Intensive Care Unit Saint Joseph Hospital Paris France
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Laetitia Marchand‐Martin
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
| | - Isabelle Guellec
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Paediatric and Neonatal Intensive Care Unit, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Medicine Sorbonne University Paris France
| | - Valérie Biran
- Neonatal Intensive Care Unit Assistance Publique – Hôpitaux de Paris CHU Robert Debré University Paris Diderot, Sorbonne Paris Cité Paris France
- Inserm U1141 University Paris Diderot, Sorbonne Paris Cité Paris France
| | - Mostafa Moktari
- Pediatric and Neonatal Intensive Care Unit Bicêtre Hospital Assistance Publique – Hôpitaux de Paris Paris France
- Espace Ethique/Ile de France ‐ Saint‐Louis Hospital Assistance Publique ‐Hôpitaux de Paris Paris France
| | - Elodie Zana‐Taieb
- Port‐Royal Maternity Neonatal Intensive Care Unit Cochin‐Port Royal Hospital Assistance Publique‐Hôpitaux de Paris Paris France
| | - Jean‐François Magny
- Neonatal Intensive Care Unit Necker‐Enfants Maladies Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Luc Desfrère
- Neonatal Intensive Care Unit Louis Mourier Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Paul Waszak
- Medicine and Neonatal Intensive Care Unit Delafontaine Hospital Saint Denis France
| | - Pascal Boileau
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal Poissy‐Saint Germain Poissy France
- Inserm U1185 Université Paris Saclay Le Kremlin‐Bicêtre France
| | - Gilles Chauvin
- Neonatal Intensive Care Unit Argenteuil Hospital Argenteuil France
| | - Laure Saint Blanquat
- Pediatric and Neonatal Intensive Care Unit Necker‐enfants Malades Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | | | - Stéphanie Droutman
- Pediatric and Neonatal Intensive Care Unit Centre Hospitalier Intercommunal André Grégoire Montreuil France
| | - Mona Merhi
- Neonatal Intensive Care Unit Centre Hospitalier Sud Francilien Corbeil‐Essonnes France
| | - Véronique Zupan
- Neonatal Intensive Care Unit Antoine Béclère Hospital Assistance Publique – Hôpitaux de Paris Clamart France
| | - Leila Karoui
- Neonatal Intensive Care Unit, Grand hôpital de l’Est francilien, site de Meaux Meaux France
| | - Patricia Cimerman
- Centre National de Ressources de lutte contre la Douleur, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Ricardo Carbajal
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Medicine Sorbonne University Paris France
- Paediatric Emergency Department, Trousseau Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - Xavier Durrmeyer
- INSERM U1153, Epidemiology and Statistics Sorbonne Paris Cité Research Center Obstetrical, Perinatal and Pediatric Epidemiology Team Paris France
- Neonatal Intensive Care Unit Centre Hospitalier Intercommunal de Créteil University Paris Est Créteil Créteil France
- Faculté de Médecine de Créteil IMRB, GRC CARMAS Université Paris Est Créteil Créteil France
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25
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Tippmann S, Haan M, Winter J, Mühler AK, Schmitz K, Schönfeld M, Brado L, Mahmoudpour SH, Mildenberger E, Kidszun A. Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations. Front Pediatr 2021; 9:675238. [PMID: 34046376 PMCID: PMC8144442 DOI: 10.3389/fped.2021.675238] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/16/2021] [Indexed: 01/11/2023] Open
Abstract
Background: Intubation of neonates is difficult and hazardous. Factors associated with procedure-related adverse events and unsuccessful intubation attempts are insufficiently evaluated, especially during neonatal nasotracheal intubations. Objective: Aim of this study was to determine the frequency of tracheal intubation-associated events (TIAEs) during neonatal nasotracheal intubations and to identify factors associated with TIAEs and unsuccessful intubation attempts in our neonatal unit. Methods: This was a prospective, single-site, observational study from May 2017 to November 2019, performed at a tertiary care neonatal intensive care unit in a German academic teaching hospital. All endotracheal intubation encounters performed by the neonatal team were recorded. Results: Two hundred and fifty-eight consecutive intubation encounters in 197 patients were analyzed. One hundred and forty-eight (57.4%) intubation encounters were associated with at least one TIAE. Intubation inexperience (<10 intubation encounters) (OR = 2.15; 95% CI, 1.257-3.685) and equipment problems (OR = 3.43; 95% CI, 1.12-10.52) were predictive of TIAEs. Intubation at first attempt (OR = 0.10; 95% CI, 0.06-0.19) and videolaryngoscopy (OR = 0.47; 96% CI, 0.25-0.860) were predictive of intubation encounters without TIAEs. The first intubation attempt was commonly done by pediatric residents (67.8%). A median of two attempts were performed until successful intubation. Restricted laryngoscopic view (OR = 3.07; 95% CI, 2.08-4.53; Cormack-Lehane grade 2 vs. grade 1), intubation by pediatric residents when compared to neonatologists (OR = 1.74; 95% CI, 1.265-2.41) and support by less experienced neonatal nurses (OR = 1.60; 95% CI, 1.04-2.46) were associated with unsuccessful intubation attempts. Conclusions: In our unit, TIAEs and unsuccessful intubation attempts occurred frequently during neonatal nasotracheal intubations. To improve success rates, quality improvement und further research should target interprofessional education and training, equipment problems and videolaryngoscopy.
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Affiliation(s)
- Susanne Tippmann
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Martin Haan
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Julia Winter
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Ann-Kathrin Mühler
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Katharina Schmitz
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Mascha Schönfeld
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Luise Brado
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Seyed Hamidreza Mahmoudpour
- Division of Medical Biostatistics and Bioinformatics, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva Mildenberger
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - André Kidszun
- Division of Neonatology, Department of Pediatrics, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Division of Neonatology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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26
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Umoren RA, Sawyer TL, Ades A, DeMeo S, Foglia EE, Glass K, Gray MM, Barry J, Johnston L, Jung P, Kim JH, Krick J, Moussa A, Mulvey C, Nadkarni V, Napolitano N, Quek BH, Singh N, Zenge JP, Shults J, Nishisaki A. Team Stress and Adverse Events during Neonatal Tracheal Intubations: A Report from NEAR4NEOS. Am J Perinatol 2020; 37:1417-1424. [PMID: 31365934 DOI: 10.1055/s-0039-1693698] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE This study aimed to examine the association between team stress level and adverse tracheal intubation (TI)-associated events during neonatal intubations. STUDY DESIGN TIs from 10 academic neonatal intensive care units were analyzed. Team stress level was rated immediately after TI using a 7-point Likert scale (1 = high stress). Associations among team stress, adverse TI-associated events, and TI characteristics were evaluated. RESULT In this study, 208 of 2,009 TIs (10%) had high stress levels (score < 4). Oxygenation failure, hemodynamic instability, and family presence were associated with high stress level. Video laryngoscopy and premedication were associated with lower stress levels. High stress level TIs were associated with adverse TI-associated event rates (31 vs. 16%, p < 0.001), which remained significant after adjusting for potential confounders including patient, provider, and practice factors associated with high stress (odds ratio: 1.90, 96% confidence interval: 1.36-2.67, p < 0.001). CONCLUSION High team stress levels during TI were more frequently reported among TIs with adverse events.
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Affiliation(s)
- Rachel A Umoren
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Taylor L Sawyer
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Anne Ades
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Stephen DeMeo
- Department of Pediatrics, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kristen Glass
- Department of Pediatrics, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania
| | - Megan M Gray
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - James Barry
- Section of Neonatology, Department of Pediatrics, University of Colorado Hospital, University of Colorado School of Medicine, Aurora, Colorado
| | - Lindsay Johnston
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Campus Luebeck, Luebeck, Germany
| | - Jae H Kim
- Department of Pediatrics, Rady Children's Hospital-San Diego, University of California, San Diego, San Diego, California
| | - Jeanne Krick
- Division of Neonatology, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Ahmed Moussa
- Department of Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Christine Mulvey
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bin Huey Quek
- Department of Neonatology, KK Women's and Children's Hospital, Singapore
| | - Neetu Singh
- Department of Pediatrics, Dartmouth Hitchcock Medical Center, West Lebanon, New Hampshire
| | - Jeanne P Zenge
- Section of Neonatology, Department of Pediatrics, University of Colorado Hospital, University of Colorado School of Medicine, Aurora, Colorado
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Delivery Room Management of Infants with Very Low Birth Weight in 3 European Countries-The Video Apgar Study. J Pediatr 2020; 222:106-111.e2. [PMID: 32418815 DOI: 10.1016/j.jpeds.2020.03.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess delivery room management of infants born preterm at 4 Level III perinatal centers in 3 European countries. STUDY DESIGN This was a prospective, multicenter observational study. Management at birth was video-recorded and evaluated (Interact version 9.6.1; Mangold-International, Arnstorf, Germany). Data were analyzed and compared within and between centers. RESULTS The infants (n = 138) differed significantly with respect to the median (25%, 75%) birth weight (grams) (Center A: 1200 [700, 1550]; Center B: 990 [719, 1240]; Center C: 1174 [835, 1435]; Center D: 1323 [971, 1515] [B vs A, C, D: P < .05]), gestational week (Center A: 28.4 [26.3, 30.0]; Center B: 27.9 [26.7, 29.6]; Center C: 29.3 [26.4, 31.0]; Center D: 30.3 [28.0, 31.9]), Apgar scores, rates of cesarean delivery, and time spent in the delivery room. Management differed significantly for frequency and drying time, rates of electrocardiographic monitoring, suctioning or stimulation, and for fundamental interventions such as time for achieving a reliable peripheral oxygen saturation signal (seconds) (Center A: 97.6 ± 79.3; Center B: 65.1 ± 116.2; Center C: 97.1 ± 67.0; Center D: 114.4 ± 140.5; B vs A, C, D: P < .001) and time for intubation (seconds) (Center A: 48.7 ± 4.2; Center B: 49.0 ± 30.7; Center C: 69.1 ±37.9; Center D: 65.1 ± 23.8; B vs D, P < .025). Mean procedural times did not meet guideline recommendations. The sequence of interventions was similar at all centers. CONCLUSIONS The Video Apgar Study showed great variability in and between 4 neonatal centers in Europe. The study also showed it is difficult to adhere to published guidelines for recommended times for important, basic measures such as peripheral oxygen saturation measurements and intubation.
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Turner JS, Bucca AW, Propst SL, Ellender TJ, Sarmiento EJ, Menard LM, Hunter BR. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e209278. [PMID: 32614424 PMCID: PMC7333022 DOI: 10.1001/jamanetworkopen.2020.9278] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Endotracheal intubation of critically ill patients is a high-risk procedure. Checklists have been advocated to improve outcomes. OBJECTIVE To assess whether the available evidence supports an association of use of airway checklists with improved clinical outcomes in patients undergoing endotracheal intubation. DATA SOURCES For this systematic review and meta-analysis, PubMed (OVID), Embase, Cochrane, CINAHL, and SCOPUS were searched without limitations using the Medical Subject Heading terms and keywords airway; management; airway management; intubation, intratracheal; checklist; and quality improvement to identify studies published between January 1, 1960, and June 1, 2019. A supplementary search of the gray literature was performed, including conference abstracts and clinical trial registries. STUDY SELECTION Full-text reviews were performed to determine final eligibility for inclusion. Included studies were randomized clinical trials or observational human studies that compared checklist use with any comparator for endotracheal intubation and assessed 1 of the predefined outcomes. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for observational studies and Cochrane risk of bias tool for randomized clinical trials. Study results were meta-analyzed using a random-effects model. Reporting of this study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES The primary outcome was mortality. Secondary outcomes included first-pass success and known complications of endotracheal intubation, including esophageal intubation, hypoxia, hypotension, and cardiac arrest. RESULTS The search identified 1649 unique citations of which 11 (3261 patients) met the inclusion criteria. One randomized clinical trial and 3 observational studies had a low risk of bias. Checklist use was not associated with decreased mortality (5 studies [2095 patients]; relative risk, 0.97; 95% CI, 0.80-1.18; I2 = 0%). Checklist use was associated with a decrease in hypoxic events (8 studies [3010 patients]; relative risk, 0.75; 95% CI, 0.59-0.95; I2 = 33%) but no other secondary outcomes. Studies with a low risk of bias did not demonstrate decreased hypoxia associated with checklist use. CONCLUSIONS AND RELEVANCE The findings suggest that use of airway checklists is not associated with improved clinical outcomes during and after endotracheal intubation, which may affect practitioners' decision to use checklists in this setting.
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Affiliation(s)
- Joseph S. Turner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Antonino W. Bucca
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Steven L. Propst
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
- Now with Department of Emergency Medicine, CoxHealth, Springfield, Missouri
| | - Timothy J. Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Elisa J. Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Laura M. Menard
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
| | - Benton R. Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
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Mari J, Franczia P, Margas W, Rutkowski J, Bebrysz M, Bokiniec R, Seliga‐Siwecka J. International consensus is needed on premedication for non-emergency neonatal intubation after survey found wide-ranging policies and practices in 70 countries. Acta Paediatr 2020; 109:1369-1375. [PMID: 31797442 DOI: 10.1111/apa.15119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/01/2019] [Accepted: 12/02/2019] [Indexed: 12/25/2022]
Abstract
AIM This study evaluated whether practitioners from 70 countries used premedication for non-emergency neonatal intubation and identified attitudes and experience regarding the safety, side effects and efficiency of neonatal intubation. METHODS Invitations to take part in the survey were issued between December 18, 2018 and February 4, 2019 to the users of neonatal-based websites and Facebook groups, members of professional societies and the authors of relevant publications in the last five years. RESULTS We analysed 718 completed questionnaires from 40 European and 30 non-European countries. Most of the responses were from neonatologists (69.6%) and paediatric or neonatal trainees (10.3%). In units without a protocol (31.6%), more than half of the practitioners (60.4%) chose premedication according to personal preference and 37.0%-11.9% of the overall respondents did not use any drugs for non-emergency intubation. The most frequently reported drug combination was fentanyl, atropine and succinylcholine (6.8%). Most of the practitioners (78.5%) use the same drugs for term and preterm infants. Only 24.8% of the physicians were fully satisfied with their premedication practices. CONCLUSION Nearly 12% of the respondents did not use premedication for non-emergency neonatal intubation. The wide-ranging policies and practices found among the respondents highlight the need for international consensus guidelines.
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Affiliation(s)
- Judit Mari
- Paediatric Department University of Szeged Szeged Hungary
| | | | | | | | | | - Renata Bokiniec
- Department of Neonatology and Neonatal intensive Care Medical University of Warsaw Warsaw Poland
| | - Joanna Seliga‐Siwecka
- Department of Neonatology and Neonatal intensive Care Medical University of Warsaw Warsaw Poland
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30
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Law BHY, Schmölzer GM. Analysis of visual attention and team communications during neonatal endotracheal intubations using eye-tracking: An observational study. Resuscitation 2020; 153:176-182. [PMID: 32580005 DOI: 10.1016/j.resuscitation.2020.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/08/2020] [Accepted: 06/10/2020] [Indexed: 01/06/2023]
Abstract
PURPOSE Eye-tracking can be used to analyse visual attention (VA) of health care providers during clinical tasks. No study has examined eye-tracking during neonatal endotracheal intubation. We aimed to examine VA and team communications during endotracheal intubation using eye-tracking in the Neonatal Intensive Care Unit. METHODS Twenty-seven video-recordings were obtained using eye-tracking glasses worn by intubators during endotracheal intubation of stable neonates. Videos were analysed to obtain i) intubation duration and success, ii) areas of interest (AOIs), iii) duration spent on each AOI, iv) types and frequency of gaze-shifts between AOIs, and v) monitor looking behaviour, and vi) team communications of vital signs and verbal medication orders. RESULTS Twenty-four videos were of acceptable quality and analysed. Median attempt duration was 44.7 s. Success rate was 79%. Overall, 50% of VA was directed at the infant, with 23% of VA directed at equipment. There were 415 gaze-shifts types and 0.55 gaze-shifts/sec. Intubators glanced at the monitor spontaneously and rarely reported vital signs afterwards. Language used to communicate vital signs and medication orders varied. CONCLUSION During neonatal intubations, 50% of VA was directed away from the infant. Team communications were non-standard. Eye-tracking can be used to analyse human performance during neonatal resuscitation.
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Affiliation(s)
- Brenda Hiu Yan Law
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada.
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
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31
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Affiliation(s)
- Taylor Sawyer
- Department of Pediatrics, Division of Neonatology, and
| | - Kaalan Johnson
- Department of Otolaryngology, Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
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32
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Breathing Easier: Decreasing Tracheal Intubation-associated Adverse Events in the Pediatric ED and Urgent Care. Pediatr Qual Saf 2019; 4:e230. [PMID: 32010856 PMCID: PMC6946226 DOI: 10.1097/pq9.0000000000000230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/05/2019] [Indexed: 12/12/2022] Open
Abstract
Supplemental Digital Content is available in the text. Tracheal intubation is a high-risk procedure in the pediatric emergency department (PED) and pediatric urgent care (PUC) settings. We aimed to develop an airway safety intervention to decrease severe tracheal intubation-associated adverse events (TIAEs) by decreasing process variation.
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Carbajal R, Lode N, Ayachi A, Chouakri O, Henry-Larzul V, Kessous K, Normand A, Courtois E, Rousseau J, Cimerman P, Chabernaud JL. Premedication practices for tracheal intubation in neonates transported by French medical transport teams: a prospective observational study. BMJ Open 2019; 9:e034052. [PMID: 31727669 PMCID: PMC6886912 DOI: 10.1136/bmjopen-2019-034052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Premedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France. SETTING This prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation. PARTICIPANTS 40 neonates intubated in 28 different centres. RESULTS The mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx-larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (p<0.001). CONCLUSION SA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent. TRIAL REGISTRATION NUMBER NCT01346813; Results.
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Affiliation(s)
- Ricardo Carbajal
- Service des Urgences Pédiatriques, Hôpital Trousseau, Paris, France
- Médecine Sorbonne Université, INSERM UMR 1153 Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Noella Lode
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Robert Debré, SAMU de Paris (AP-HP), Paris, France
| | - Azzedine Ayachi
- Neonatal Transport Team, SMUR Pédiatrique, SAMU de Seine Saint Denis (AP-HP), Montreuil, France
| | - Ourida Chouakri
- Neonatal Transport Team, SMUR Pédiatrique Necker, Hôpital Necker, SAMU de Paris (AP-HP), Paris, France
| | | | - Katia Kessous
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Robert Debré, SAMU de Paris (AP-HP), Paris, France
| | - Audrey Normand
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Antoine Béclère, SAMU des Hauts de Seine, Hôpitaux Universitaires Paris-Sud (AP-HP), Clamart, Hauts de Seine, France
| | - Emilie Courtois
- Paediatric Emergency Department, Assitance Publique-Hôpitaux de Paris, Paris, France
| | - Jessica Rousseau
- INSERM UMR 1153 Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Paris, France
| | - Patricia Cimerman
- Centre National de Ressources de Lutte Contre la Douleur, Hopital Armand Trousseau, Paris, France
| | - Jean-Louis Chabernaud
- Neonatal Transport Team, SMUR Pédiatrique, Hôpital Antoine Béclère, SAMU des Hauts de Seine, Hôpitaux Universitaires Paris-Sud (AP-HP), Clamart, Hauts de Seine, France
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Decreasing Time from Decision to Intubation in Premedicated Neonates: A Quality Improvement Initiative. Pediatr Qual Saf 2019; 4:e234. [PMID: 32010860 PMCID: PMC6946237 DOI: 10.1097/pq9.0000000000000234] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/18/2019] [Indexed: 12/27/2022] Open
Abstract
Endotracheal intubation carries the risk of discomfort, decompensation, oral trauma, and endotracheal tube malposition. Treatment with premedications reduces complications, increases overall intubation safety, improves pain control, and improves first-pass success. However, time is frequently a barrier to administration. We aimed to decrease the decision-to-intubation time interval from a baseline of 40 minutes to less than 35 minutes over 6 months.
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Cobo P, Vetter-Laracy S, Beltran E, Peña-Zarza JA, Figuerola J, Osona B. Utility of fiberoptic bronchoscopy for difficult airway in neonates. J Matern Fetal Neonatal Med 2019; 34:2754-2757. [PMID: 31575302 DOI: 10.1080/14767058.2019.1670801] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Newborns diagnosed with craniofacial malformations or laryngeal and tracheal alterations may often need advanced airway-management for airway stabilization. Although fiberoptic bronchoscopy (FB) is currently the gold standard for difficult airway management, there is a scarcity of published data on the application of FB in newborns for intubation and controlled extubation (CE). OBJECTIVES This study describes a case series where FB is used for intubation and/or extubation to manage newborns with difficult airway in either urgent procedures or scheduled ones. METHODS All FB were carried out on newborns with difficult airway in the neonatal unit over the period January 2005 to December 2018. Patient characteristics were collected from clinical reports, description of the technique from the procedure report. RESULTS 66 FBs were performed from a total of 40 newborns, a median age of 25 days and a weight of 3217 g. Eighteen were ex-premature babies (45%). Six (15%) had craniocervical malformations. 17 (25.7%) FBs were performed for tracheal intubation (TI), 6 in emergency situations, 34 (51.5%) for CE, and 15 (22.7%) for precise tube placement. Clearing of the airway was achieved in all cases and thus there were no failed TIs. In 32 cases (94.1%), CE was successfully performed. In 6 cases, withdrawal of the ET midprocedure was decided to postpone as 4 of these required extra treatment prior to renewed extubation attempt and 2 needed a tracheostomy. 2 patients required subsequent FB reintubation due to airway pathology. Complications during the procedure were mild desaturations (3%) and deep desaturations (7.5%). CONCLUSIONS FB is very safe and highly useful when performing intubation in neonates with difficult airway but is essential during extubation to avoid any risk of failure with a potentially fatal outcome. Neonatal units of tertiary hospitals should provide equipment and training to manage these neonates. WHAT IS ALREADY KNOWN? A failed intubation or extubation can lead to cardiac arrest and anoxic brain damage and/or to death in a neonate. Fiberoptic bronchoscopy is recommended as the safest tool for neonates with difficult airway. However, there is little concrete data published in the current literature to support the recommendations. WHAT IS NEW Fiberoptic bronchoscopy is an essential tool to avoid the risk of a failed extubation in neonates with difficult airway.
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Affiliation(s)
- Pilar Cobo
- Division of Neonatology, Department of Pediatrics, University Hospital Son Espases, Palma de Mallorca, Spain.,Pediatric Multidisciplinary Research Group of Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
| | - Susanne Vetter-Laracy
- Division of Neonatology, Department of Pediatrics, University Hospital Son Espases, Palma de Mallorca, Spain.,Pediatric Multidisciplinary Research Group of Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
| | - Eva Beltran
- Division of Neonatology, Department of Pediatrics, University Hospital Son Espases, Palma de Mallorca, Spain.,Pediatric Multidisciplinary Research Group of Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
| | - José Antonio Peña-Zarza
- Department of Pediatrics, Division of Pediatric Respiratory Medicine, University Hospital Son Espases, Palma de Mallorca, Spain.,Sleep Apneas and Hypopneas Research Group of Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain
| | - Joan Figuerola
- Pediatric Multidisciplinary Research Group of Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain.,Department of Pediatrics, Division of Pediatric Respiratory Medicine, University Hospital Son Espases, Palma de Mallorca, Spain
| | - Borja Osona
- Pediatric Multidisciplinary Research Group of Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Spain.,Department of Pediatrics, Division of Pediatric Respiratory Medicine, University Hospital Son Espases, Palma de Mallorca, Spain
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Hatch LD, Rivard M, Bolton J, Sala C, Araya W, Markham MH, France DJ, Grubb PH. Implementing Strategies to Identify and Mitigate Adverse Safety Events: A Case Study with Unplanned Extubations. Jt Comm J Qual Patient Saf 2019; 45:295-303. [PMID: 30583986 PMCID: PMC6491248 DOI: 10.1016/j.jcjq.2018.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patient safety events result from failures in complex health care delivery processes. To ensure safety, teams must implement ways to identify events that occur in a nonrandom fashion and respond in a timely manner. To illustrate this, one children's hospital's experience with an outbreak of unplanned extubations (UEs) in the neonatal ICU (NICU) is described. METHODS The quality improvement team measured UEs using three complementary data streams. Interventions to decrease the rate of UE were tested with success. Three statistical process control (SPC) charts (u-chart, g-chart, and an exponentially weighted moving average [EWMA] chart) were used for real-time monitoring. RESULTS From July 2015 to May 2016, the UE rate was stable at 1.1 UE/100 ventilator days. In early June 2016, a cluster of UEs, including four events within one week, was observed. Two of three SPC charts showed special cause variation, although at different time points. The EWMA chart alerted the team more than two weeks earlier than the u-chart. Within days of discovering the outbreak, the team identified that the hospital had replaced the tape used to secure endotracheal tubes with a nearly identical product. After multiple tape products were tested over the next month, the team selected one that returned the system to a state of stability. CONCLUSION Ongoing monitoring using SPC charts allowed early detection and rapid mitigation of an outbreak of UEs in the NICU. This highlights the importance of continuous monitoring using tools such as SPC charts that can alert teams to both improvement and worsening of processes.
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Cook TM, Kelly FE, Foy K, Mew E, Bower J, Marden B, Dean S, Knight P, Herneman K. The PIC-NIC survey: capnography and neonatal intensive care - a reply. Anaesthesia 2019; 74:118-120. [PMID: 30511756 DOI: 10.1111/anae.14529] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- T M Cook
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - F E Kelly
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - K Foy
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - E Mew
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - J Bower
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - B Marden
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - S Dean
- Bristol Royal Hospital for Children, Bristol, UK
| | - P Knight
- Bristol Royal Hospital for Children, Bristol, UK
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Foglia EE, Ades A, Sawyer T, Glass KM, Singh N, Jung P, Quek BH, Johnston LC, Barry J, Zenge J, Moussa A, Kim JH, DeMeo SD, Napolitano N, Nadkarni V, Nishisaki A. Neonatal Intubation Practice and Outcomes: An International Registry Study. Pediatrics 2019; 143:peds.2018-0902. [PMID: 30538147 PMCID: PMC6317557 DOI: 10.1542/peds.2018-0902] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety. METHODS We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression. RESULTS We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57). CONCLUSIONS We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Ades
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Taylor Sawyer
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Kristen M. Glass
- Penn State Health Children’s Hospital and Penn State College of Medicine, Hershey, Pennsylvania
| | - Neetu Singh
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Philipp Jung
- Department of Pediatrics, University Hospital Schleswig Holstein, Campus Luebeck, Luebeck, Germany
| | - Bin Huey Quek
- KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Lindsay C. Johnston
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - James Barry
- Department of Pediatrics, Section of Neonatology, School of Medicine, University of Colorado, Aurora, Colorado
| | - Jeanne Zenge
- Department of Pediatrics, Section of Neonatology, School of Medicine, University of Colorado, Aurora, Colorado
| | - Ahmed Moussa
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Jae H. Kim
- Division of Neonatology, Department of Pediatrics, University of California, San Diego and Rady Children’s Hospital of San Diego, San Diego, California
| | | | - Natalie Napolitano
- Departments of Nursing, Respiratory Care and Neurodiagnostic Services and
| | - Vinay Nadkarni
- Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Akira Nishisaki
- Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
Within emergency care settings, rapid sequence intubation (RSI) is frequently used to secure a definitive airway (i.e., endotracheal tube) to provide optimal oxygenation and ventilation in critically ill patients of all ages. For providers in these settings, a deeper understanding of the indications, associated medications, and adjunctive techniques may maximize success with this common procedure. Identification of difficult airways, using mnemonics and standardized criteria prior to the procedure allows, the clinician additional time for assimilation of additional resources and tools to increase the likelihood of first-pass success with intubation. This article describes tools for the procedure of RSI, including the "7 Ps" checklist of intubation.
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40
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Foy KE, Mew E, Cook TM, Bower J, Knight P, Dean S, Herneman K, Marden B, Kelly FE. Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC-NIC survey. Anaesthesia 2018; 73:1337-1344. [PMID: 30112809 DOI: 10.1111/anae.14359] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2018] [Indexed: 12/18/2022]
Abstract
In 2011, the Fourth National Audit Project (NAP4) reported high rates of airway complications in adult intensive care units (ICUs), including death or brain injury, and recommended preparation for airway difficulty, immediately available difficult airway equipment and routine use of waveform capnography monitoring. More than 80% of UK adult intensive care units have subsequently changed practice. Undetected oesophageal intubation has recently been listed as a 'Never Event' in UK practice, with capnography mandated. We investigated whether the NAP4 recommendations have been embedded into paediatric and neonatal intensive care practice by conducting a telephone survey of senior medical or nursing staff in UK paediatric intensive care units (PICUs) and neonatal intensive care units (NICUs). Response rates were 100% for paediatric intensive care units and 90% for neonatal intensive care units. A difficult airway policy existed in 67% of paediatric intensive care units and in 40% of neonatal intensive care units; a pre-intubation checklist was used in 70% of paediatric intensive care units and in 42% of neonatal intensive care units; a difficult intubation trolley was present in 96% of paediatric intensive care units and in 50% of neonatal intensive care units; a videolaryngoscope was available in 55% of paediatric intensive care units and in 29% of neonatal intensive care units; capnography was 'available' in 100% of paediatric intensive care units and in 46% of neonatal intensive care units, and 'always available' in 100% of paediatric intensive care units and in 18% of neonatal intensive care units. Death or serious harm occurring secondary to complications of airway management in the last 5 years was reported in 19% of paediatric intensive care units and in 26% of neonatal intensive care units. We conclude that major gaps in optimal airway management provision exist in UK paediatric intensive care units and especially in UK neonatal intensive care units. Wider implementation of waveform capnography is necessary to ensure compliance with the new 'Never Event' and has the potential to improve airway management.
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Affiliation(s)
- K E Foy
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - E Mew
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - J Bower
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - P Knight
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
| | - S Dean
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
| | - K Herneman
- Department of Anaesthesia, Southmead Hospital, Bristol, UK
| | - B Marden
- Neonatal Intensive Care Unit, Royal United Hospital, Bath, UK
| | - F E Kelly
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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Abstract
Endotracheal intubation, a common procedure in neonatal intensive care, results in distress and disturbs physiologic homeostasis in the newborn. Analgesics, sedatives, vagolytics, and/or muscle relaxants have the potential to blunt these adverse effects, reduce the duration of the procedure, and minimize the number of attempts necessary to intubate the neonate. The medical care team must understand efficacy, safety, and pharmacokinetic data for individual medications to select the optimal cocktail for each clinical situation. Although many units utilize morphine for analgesia, remifentanil has a superior pharmacokinetic profile and efficacy data. Because of hypotensive effects in preterm neonates, sedation with midazolam should be restricted to near-term and term neonates. A vagolytic, generally atropine, blunts bradycardia induced by vagal stimulation. A muscle relaxant improves procedural success when utilized by experienced practitioners; succinylcholine has an optimal pharmacokinetic profile, but potentially concerning adverse effects; rocuronium may be the agent of choice based on more robust safety data despite a relatively prolonged duration of action. In the absence of an absolute contraindication, neonates should receive analgesia with consideration of sedation, a vagolytic, and a muscle relaxant before endotracheal intubation. Neonatal units must develop protocols for premedication and optimize logistics to ensure safe and timely administration of appropriate agents.
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42
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Moving from controversy to consensus: premedication for neonatal intubation. J Perinatol 2018; 38:611-613. [PMID: 29930326 DOI: 10.1038/s41372-018-0115-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 03/12/2018] [Indexed: 12/23/2022]
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Davidson LA, Utarnachitt RB, Mason A, Sawyer T. Development and Testing of a Neonatal Intubation Checklist for an Air Medical Transport Team. Air Med J 2018; 37:41-45. [PMID: 29332775 DOI: 10.1016/j.amj.2017.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/29/2017] [Accepted: 09/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We developed a Neonatal Intubation Checklist for Airlift Northwest. Our goal was to improve the preparation, technical proficiency, and safety of neonatal intubation without increasing the time required to perform the procedure. METHODS The Neonatal Intubation Checklist, a "call and response" checklist for neonatal intubation, was developed. Its effectiveness was evaluated during a baseline assessment and 2 practice sessions after a checklist orientation. Intubation proficiency was evaluated using a validated assessment tool that included a proficiency score, a global rating scale (GRS) score, and time to perform the procedure. RESULTS Significant improvements in intubation proficiency and time to intubation were noted when teams used the intubation checklist (proficiency score: 29 [7] at baseline vs. 57 [1] with checklist, P < .001; GRS 2 [2, 2.5] at baseline vs. 5 [3, 5] with checklist, P < .001; baseline intubation time 626 [93] seconds vs. 479 (44) seconds with checklist, P < .001). These changes were associated with a large effect on proficiency (ƞ2 = 0.89), GRS (ƞ2 = 0.6), and time to successful intubation (ƞ2 = 0.52). CONCLUSION The use of the Neonatal Intubation Checklist improved transport team performance during simulated neonatal intubations and decreased the time required to successfully perform the procedure.
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Affiliation(s)
- Lisa A Davidson
- Airlift Northwest, Department of Pediatrics, Division of Neonatology, Seattle, WA.
| | | | - Andrew Mason
- Airlift Northwest, Department of Pediatrics, Division of Neonatology, Seattle, WA
| | - Taylor Sawyer
- Airlift Northwest, Department of Pediatrics, Division of Neonatology, Seattle, WA
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