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Khanam D, Schoenfeld E, Ginsberg-Peltz J, Lutfy-Clayton L, Schoenfeld DA, Spirko B, Brown CA, Nishisaki A. First-Pass Success of Intubations Using Video Versus Direct Laryngoscopy in Children With Limited Neck Mobility. Pediatr Emerg Care 2024; 40:454-458. [PMID: 37751531 DOI: 10.1097/pec.0000000000003058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE It is not clear whether video laryngoscopy (VL) is associated with a higher first-pass success rate in pediatric patients with limited neck mobility when compared with direct laryngoscopy (DL). We sought to determine the association between the laryngoscopy method and first-pass success. METHODS In this retrospective cohort study, we examined intubation data extracted from 2 prospectively collected, multicenter, airway management safety databases (National Emergency Airway Registry and the National Emergency Airway Registry for children), obtained during the years 2013-2018 in the emergency department. Intubations were included if patients were aged younger than 18 and had limited neck mobility. We compared first-pass success rates for ED intubations that were performed using VL versus DL. We built a structural causal model to account for potential confounders such as age, disease category (medical or trauma condition), other difficult airway characteristics, use of sedatives/paralytics, and laryngoscopist training level. We also analyzed adverse events as a secondary outcome. RESULTS Of 34,239 intubations (19,071 in the National Emergency Airway Registry and 15,168 in the National Emergency Airway Registry for children), a total of 341 intubations (1.0%) met inclusion criteria; 168 were performed via VL and 173 were performed via DL. The median age of patients was 124 months (interquartile range, 48-204). There was no difference in first-pass success between VL and DL (79.8% vs 75.7%, P = 0.44). Video laryngoscopy was not associated with higher first-pass success (odds ratio, 1.11; 95% confidence interval 0.84-1.47, with DL as a comparator) when a structural causal model was used to account for confounders. There was no difference in the adverse events between VL and DL groups (13.7% vs 8.7%, P = 0.19). CONCLUSION In children with limited neck mobility receiving tracheal intubation in the ED, neither VL nor DL was associated with a higher first-pass success rate.
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Affiliation(s)
- Dilruba Khanam
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Elizabeth Schoenfeld
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Julien Ginsberg-Peltz
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Lucienne Lutfy-Clayton
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | | | - Blake Spirko
- From the Department of Emergency Medicine, UMass Chan Medical School-Baystate, Springfield, MA
| | - Calvin A Brown
- Department of Emergency Medicine, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
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Davis DP, Chandran K, Noce J. A Descriptive Analysis of Air Medical Pediatric Rapid Sequence Intubation: Successes and Opportunities. Air Med J 2024; 43:210-215. [PMID: 38821700 DOI: 10.1016/j.amj.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/10/2024] [Accepted: 02/14/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Advanced airway management, including the use of rapid sequence intubation (RSI), is fundamental in resuscitation. However, the reported experience with pediatric airway management is limited because of the relatively low number of emergency RSI procedures in children. The aim of this study was to document the experience with pediatric RSI in a large air medical database and explore opportunities for improvement. METHODS All pediatric patients (age < 18 years) undergoing RSI by air medical crews between 2015 and 2019 were included in this analysis. Subjects were divided a priori into 3 age subgroups (0-2 years, 3-8 years, and 9-17 years). The primary variables of interest included overall intubation success, first-attempt intubation success, and first-attempt intubation success without desaturation. The rates of positive-pressure ventilation (PPV) use for preoxygenation and oxygen desaturation were also explored. RESULTS A total of 1,091 pediatric RSI patients were included. The overall intubation success rate was 98% (0-2 years = 96%, 3-8 years = 97%, and 9-17 years = 98%), with 91% intubated on the first attempt (0-2 years = 86%, 3-8 years = 90%, and 9-17 years = 92%) and 87% intubated on the first attempt without oxygen desaturation (0-2 years = 80%, 3-8 years = 88%, and 9-17 years = 90%). A sharp decline in intubation success was observed with preoxygenation SpO2 values < 97% across all patients. Younger patients (0-2 years) had lower initial SpO2 values and decreased first-attempt success rates with and without desaturation. These patients were less likely to receive PPV during preoxygenation attempts and had lower use of video laryngoscopy or a bougie on the initial intubation attempt. CONCLUSION In this study, we documented high success rates for air medical pediatric RSI. Higher target SpO2 values may be justified during preoxygenation. Intubation success, PPV use for preoxygenation, video laryngoscopy, and the use of a bougie were lower for younger patients.
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Affiliation(s)
- Daniel P Davis
- Logan Health, Division of EMS, Kalispell, MT; Air Methods Corporation, Greenwood Village, CO.
| | - Kira Chandran
- Georgetown School of Medicine, Georgetown, Washington DC; Harvard Affiliated Emergency Medicine Program, Boston, MA
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3
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Kaniecki DM, Grabowski RL, Holloway D, Brown A, Lorenz LA. Nurse Practitioners in Critical Care Transport. Air Med J 2024; 43:163-167. [PMID: 38490781 DOI: 10.1016/j.amj.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/04/2023] [Accepted: 01/04/2024] [Indexed: 03/17/2024]
Abstract
The inclusion of nurse practitioners (NPs) in critical care transport teams has the potential to enhance patient care and improve team operations. NPs can manage complex clinical situations during transport and excel in various roles such as leadership, education, mentoring, research, quality improvement, and clinical expertise. As we navigate the evolving landscape of critical care transport, it is crucial to explore the potential benefits offered by NPs. Their distinct skills and experiences effectively position them to improve patient outcomes, enhance team performance, and contribute to health care's financial sustainability. This article discusses the role of NPs in critical care transport, providing insight into their current uses, and recommendations for optimal use.
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Affiliation(s)
- David M Kaniecki
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH; Cleveland Metro Life Flight, MetroHealth System, Cleveland, OH.
| | - Robert L Grabowski
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH; Cleveland Metro Life Flight, MetroHealth System, Cleveland, OH
| | - David Holloway
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH; Cleveland Clinic Critical Care Transport, Cleveland Clinic, Cleveland, OH
| | - Abigail Brown
- Cleveland Clinic Critical Care Transport, Cleveland Clinic, Cleveland, OH
| | - Lisa A Lorenz
- Cleveland Clinic Critical Care Transport, Cleveland Clinic, Cleveland, OH
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4
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Sugaya A, Naito K, Goto T, Hagiwara Y, Okamoto H, Watase H, Hasegawa K. First-Pass Success of Video Laryngoscope Compared With Direct Laryngoscope in Intubations Performed by Residents in the Emergency Department. Cureus 2023; 15:e47563. [PMID: 38021629 PMCID: PMC10665768 DOI: 10.7759/cureus.47563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND The video laryngoscope (VL) has been widely used for intubation in the emergency department (ED). However, their effectiveness remains controversial, particularly among airway management performed by residents in the ED. METHODS We aimed to examine whether the use of VL, compared to a direct laryngoscope (DL), was associated with higher first-attempt intubation success among intubations performed by residents in the ED. This is a secondary analysis of the data from a prospective, observational, multicentre study of 15 Japanese EDs from April 2012 through March 2020. We included all adult patients who underwent intubation with VL or DL by residents (postgraduate years ≤5) in the ED. The outcome measures were first-pass success and intubation-related adverse events (overall, major, and minor adverse events). To determine the association of VL use with each of the outcomes, we constructed logistic regression models with generalized estimating equations to account for patients clustering within the ED, adjusting for patient demographics, primary indications, intubation difficulty, and intubation methods. RESULTS Of 5,261 eligible patients who underwent an initial intubation attempt by residents, 1,858 (35%) patients were attempted with VL. Intubations performed with VL had a non-significantly higher first-pass success rate than those with DL (77% vs. 64%; unadjusted odds ratio (OR)=1.20; 95% CI=0.87-1.65; P=0.27). This association was significant after adjustment for potential confounders (adjusted OR, 1.33; 95% CI, 1.06-1.67; P=0.01). As for adverse events, the use of VL was associated with a lower rate of any (adjusted OR=0.67; 95% CI=0.51-0.86; P=0.002) and minor (adjusted OR=0.69; 95% CI=0.55-0.87; P=0.002) adverse events. CONCLUSION The use of VL was associated with a higher first-attempt success rate and a lower rate of any adverse events compared to that with DL among intubations performed by residents in the EDs.
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Affiliation(s)
- Akihiko Sugaya
- Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, JPN
| | - Keiko Naito
- Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, JPN
| | - Tadahiro Goto
- Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, JPN
| | - Yusuke Hagiwara
- Paediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Hiroshi Okamoto
- Critical Care Medicine, St. Luke's International Hospital, Tokyo, JPN
| | - Hiroko Watase
- Emergency Medicine and General Internal Medicine, School of Medicine, Fujita Health University, Aichi, JPN
| | - Kohei Hasegawa
- Emergency Medicine, Massachusetts General Hospital, Boston, USA
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5
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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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6
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Kolewe EL, Padhye S, Woodward IR, Feng Y, Briddell JW, Fromen CA. A Pediatric Upper Airway Library to Evaluate Interpatient Variability of In Silico Aerosol Deposition. AAPS PharmSciTech 2023; 24:162. [PMID: 37523076 PMCID: PMC10660588 DOI: 10.1208/s12249-023-02619-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023] Open
Abstract
The airway of pediatric patients' changes through development, presenting a challenge in developing pediatric-specific aerosol therapeutics. Our work aims to quantify geometric variations and aerosol deposition patterns during upper airway development in subjects between 3.5 months-6.9 years old using a library of 24 pediatric models and 4 adult models. Computational fluid-particle dynamics was performed with varying particle size (0.1-10 μm) and flow rate (10-120 Lpm), which was rigorously analyzed to compare anatomical metrics (epiglottis angle (θE), glottis to cricoid ring ratio (GC-ratio), and pediatric to adult trachea ratio (H-ratio)), inhaler metrics (particle diameter, [Formula: see text], and flow rate, Q), and clinical metrics (age, sex, height, and weight) against aerosol deposition. Multivariate non-linear regression indicated that all metrics were all significantly influential on resultant deposition, with varying influence of individual parameters. Additionally, principal component analysis was employed, indicating that [Formula: see text], Q, GC-ratio, θE, and sex accounted for 90% of variability between subject-specific deposition. Notably, age was not statistically significant among pediatric subjects but was influential in comparing adult subjects. Inhaler design metrics were hugely influential, thus supporting the critical need for pediatric-specific inhalable approaches. This work not only improves accuracy in prescribing inhalable therapeutics and informing pediatric aerosol optimization, but also provides a framework for future aerosol studies to continue to strive toward optimized and personalized pediatric medicine.
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Affiliation(s)
- Emily L Kolewe
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA
| | - Saurav Padhye
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA
| | - Ian R Woodward
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA
| | - Yu Feng
- Department of Chemical Engineering, Oklahoma State University, Stillwater, Oklahoma, USA
| | - Jenna W Briddell
- Division of Otorhinolaryngology, Department of Surgery, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Catherine A Fromen
- Department of Chemical and Biomolecular Engineering, University of Delaware, 150 Academy St., Newark, Delaware, 19716, USA.
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Prekker ME, Bjorklund AR, Myers C, Harvey L, Horton GB, Goldstein J, Usher SC, Reardon RF, Robinson A, Strobel AM, Driver BE. The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children. Ann Emerg Med 2023; 81:667-676. [PMID: 36841658 DOI: 10.1016/j.annemergmed.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE Bougie use during emergency tracheal intubation has not been well studied in children. METHODS This was a 10-year observational study of pediatric intubations (<18 years of age) in the emergency department (ED) of an academic institution. Bougie training and use are standard in our ED, including for emergency medicine residents. Study data were collected by a combination of charts and video reviews. We compare first-attempt intubation success and procedural complications between pediatric patients with and without bougie use during tracheal intubation in the ED. In addition, we evaluate the independent association of bougie use with first-attempt intubation success using multivariable logistic regression. RESULTS We collected data on intubation success and bougie use for 195 pediatric patients over more than 10 years. On the first tracheal intubation attempt, a pediatric bougie was used in 126 patients (65%). Median patient age was 5 years (interquartile range 1.7 to 9) in the bougie group and 1.7 years (interquartile range 0.2 to 5) in the no bougie group. Intubation was successful on the first attempt in 72% of intubations with a bougie versus 78% without a bougie (absolute difference -6%, 95% confidence interval [CI] -19 to 6%); the adjusted odds of first-attempt success with a bougie were 0.54 (95% CI 0.24 to 1.19). A procedural complication occurred for 38% of patients in the bougie group versus 51% in the no bougie group (-13%, 95% CI -27% to 2%). Two neonates, one in each group, experienced a potential injury to the airway or lower respiratory tract. CONCLUSION In an academic ED where the bougie is commonly used, bougie use in children was not associated with procedural success or complications. Our study suggests that a randomized clinical trial is needed to determine the effect of bougie use during emergency pediatric intubation.
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Affiliation(s)
- Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center; Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hennepin County Medical Center.
| | - Ashley R Bjorklund
- Division of Pediatric Critical Care, Department of Pediatrics, Hennepin County Medical Center, and the University of Minnesota, M Health Masonic Children's Hospital
| | - Carrie Myers
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Lauren Harvey
- Department of Emergency Medicine, Hennepin County Medical Center
| | | | - Jack Goldstein
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Sarah C Usher
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Aaron Robinson
- Department of Emergency Medicine, Hennepin County Medical Center
| | - Ashley M Strobel
- Division of Emergency Medicine and Child Advocacy, Department of Pediatrics, University of Minnesota, M Health Masonic Children's Hospital, Minneapolis, MN
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center
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VanDeWall A, Harris-Kober S, Farooqi A, Kannikeswaran N. Peri-Intubation Arrest in High Risk vs. Standard Risk Pediatric Trauma Patients Undergoing Endotracheal Intubation. Am J Emerg Med 2023; 67:79-83. [PMID: 36806979 DOI: 10.1016/j.ajem.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND While the anatomically difficult airway has been studied in pediatric trauma patients, physiologic risk factors are poorly understood. Our objective was to evaluate if previously published high risk physiologic criteria for difficult airway in medical patients is associated with adverse outcomes in pediatric trauma patients. METHODS This was a retrospective chart review of patients ≤18 years with traumatic injuries who underwent endotracheal intubation (EI) in a pediatric emergency department (PED) between 2016 and 2021. High risk criteria evaluated included 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation. Our primary outcome was peri-intubation cardiac arrest, defined as cardiac arrest within 10 minutes of EI. Secondary outcomes included in-hospital cardiac arrest and mortality and first pass EI success. RESULTS One third (n = 32; 36.4%) of the 88 patients analyzed had at least one high risk criteria. When compared to the standard risk group, those in the high risk group had a higher incidence of peri-intubation arrest (28.1% vs. 0%, difference: 28.1%, 95% CI: 10.1-46.2), PED/in-hospital arrest (43.8% vs. 3.4%, difference: 38.4%, 95% CI: 17.8-59.0) and in-hospital mortality (33.4% vs. 3.6%, difference: 29.8%, 95% CI: 8.4-46.9). Having multiple high risk criteria progressively increased the odds of post-intubation PED/in-hospital cardiac arrest (1 risk factor: OR = 6.7, 95% CI: 1.5-30.2; 2 risk factors: OR = 12.5, 95% CI: 2.3-70.0; ≥ 3 risk factors: OR = 56.1, 95% CI: 6.0-523.8). CONCLUSIONS The presence of high risk physiologic criteria is associated with increased incidence of peri-intubation, in-hospital arrest, and death in pediatric trauma patients. Children with multiple risk factors are at an incremental risk of cardiac arrest.
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Affiliation(s)
- Audrey VanDeWall
- Pediatric Emergency Medicine Fellow, Division of Emergency Medicine, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, United States of America.
| | - Sarah Harris-Kober
- Pediatric Resident, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, United States of America.
| | - Ahmad Farooqi
- Research Assistant (Biostatistician), Department of Pediatrics, Central Michigan University, Detroit, MI 48201, United States of America
| | - Nirupama Kannikeswaran
- Professor of Pediatrics & Emergency Medicine, Central Michigan University, Division of Emergency Medicine, Children's Hospital of Michigan, 3901, Beaubien Blvd, Detroit, MI 48201, United States of America.
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Cao Y, Jiang L, Zhang Y, Yao W, Chen Y, Dai Z. An optimal tracheal tube preshaping strategy for endotracheal intubation using video laryngoscopy: a randomized controlled trial. J Clin Monit Comput 2022; 36:1629-1634. [PMID: 35083623 DOI: 10.1007/s10877-022-00806-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 01/03/2022] [Indexed: 11/28/2022]
Abstract
Although video laryngoscopy solves the problem of glottis exposure, it is difficult to deliver the tube to the glottic opening when the tracheal tube is unevenly shaped. This study aimed to compare the effects of different tube shapes on the first-pass success (FPS) rate in patients undergoing video laryngoscopy-assisted tracheal intubation. Three hundred patients above 18 years of age who underwent general anaesthesia and required endotracheal intubation were included in the study. The participants were randomly allocated to three groups with 100 participants in each group as follows: Group A, video laryngoscopes with a self-equipped stylet are used for tube preshaping; Group B: curvature of the video laryngoscope blade is modelled for tube preshaping; Group C: tube preshaping angle is consistent with the video laryngoscope blade, and the bending point is set 1 cm above the tracheal tube cuff. The primary outcome was FPS rates. The secondary outcomes included time to tracheal intubation, haemodynamic responses and adverse events. No significant differences in patient characteristics or airway assessments were noted (P > 0.05). Compared with Groups A, Group B and Group C exhibited a higher FPS rate (68% vs. 86% vs. 92%; P < 0.001). However, there is no significant difference in FPS rate between Group B and Group C (P > 0.05). And the time to tracheal intubation in Group C was significantly less than that in Group A and Group B (22.21 ± 4.01 vs. 19.92 ± 4.11 vs. 17.71 ± 3.47; P < 0.001). The straight-to-cuff stylet preshape angulation of curvature of the blade could provide a higher FPS rate and shorter time to tracheal intubation during video laryngoscopy-assisted endotracheal intubation. Trial registration: Chinese Clinical Trial Registry, ChiCTR1900026019.
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Affiliation(s)
- Ya Cao
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Lianxiang Jiang
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Yan Zhang
- Department of Anaesthesia, Tongling People's Hospital, Tongling, Anhui, China
| | - Weidong Yao
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Yongquan Chen
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China
| | - Zeping Dai
- Department of Anaesthesia, the First Affiliated Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu, Anhui, China.
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10
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Hagiwara Y, Goto T, Ohnishi S, Miyamoto D, Ikeyama Y, Matsunami K, Hasegawa K. Airway management in the pediatric emergency department in Japan: A multicenter prospective observational study. Acute Med Surg 2022; 9:e798. [PMID: 36203851 PMCID: PMC9525619 DOI: 10.1002/ams2.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 09/14/2022] [Indexed: 11/09/2022] Open
Abstract
Aim Tracheal intubation is a vital resuscitation procedure in the pediatric emergency department (ED). Despite its importance, little is known about the current status of emergency airway management in Japan. In this context, we aimed to investigate the airway management characteristics-particularly the location, patient, and provider factors-in the pediatric ED. Methods We conducted a multicenter, prospective study of five pediatric EDs in Japan from October 2018 to June 2020. The study included all children (aged ≤18 years) who underwent intubation at the pre-ED or ED setting by physicians and those who were transferred from the ED to the operation room (OR) or pediatric intensive care unit (PICU) for intubation. We described the airway management characteristics according to the location, patient, and provider factors. Results Of 231 children, 9 (4%) were transferred to the OR or PICU for airway management. Among the remaining 222 children, 45 were intubated at the pre-ED setting and 177 were intubated in the ED. The overall first-attempt success rate was 72%, with the rate varying by location, patient, and provider factors-for example, 68% at the pre-ED setting, 67% for children <2 years, 56% for children with airway-related anatomical anomalies, and 61% with intubation by a resident physician. Intubation-related adverse events were observed in 17%, most of which were hypoxemia (14%). Conclusions Based on data from a multicenter prospective study, the overall first-attempt intubation success rate in pediatric EDs in Japan was 72%, with large variations by location, patient, and provider factors.
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Affiliation(s)
- Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care MedicineTokyo Metropolitan Children's Medical CenterTokyoJapan
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public HealthThe University of TokyoTokyoJapan
| | - Shima Ohnishi
- Division of Emergency and Transport ServicesNational Center for Child Health and DevelopmentTokyoJapan
| | - Daisuke Miyamoto
- Department of Pediatric Emergency MedicineSaitama Children's Medical CenterSaitamaJapan
| | - Yuki Ikeyama
- Department of Pediatric Emergency MedicineAichi Children's Health and Medical CenterObu‐shi, AichiJapan
| | - Kunihiro Matsunami
- Department of PediatricsGifu Prefectural General Medical CenterGifuJapan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMA
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Impact of Intubator's Training Level on First-Pass Success of Endotracheal Intubation in Acute Care Settings: A Four-Center Retrospective Study. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9070960. [PMID: 35883944 PMCID: PMC9322935 DOI: 10.3390/children9070960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
(1) Background: First-pass success (FPS) of endotracheal intubation is more challenging in children than in adults. We aimed to identify factors associated with FPS of intubation in acute care settings. (2) Methods: We analyzed data of children aged <10 years who underwent intubation within ≤24 h of arrival at four Korean emergency departments (2016−2019). Variables were compared according to FPS. A logistic regression was performed to quantify the association of factors with FPS. An experienced intubator was defined as a senior resident or a specialist. (3) Results: Of 280 children, 169 (60.4%) had FPS. The children with FPS were older (median age, 23.0 vs. 11.0 months; p = 0.018), were less frequently in their infancy (36.1% vs. 50.5%; p = 0.017), and were less likely to have respiratory compromise (41.4% vs. 55.0%; p = 0.030). The children with FPS tended to be more often intubated by experienced intubators than those without FPS (87.0% vs. 78.4%; p = 0.057). Desaturation was rarer in those with FPS. Factors associated with FPS were experienced intubators (aOR, 1.93; 95% CI, 1.01−3.67) and children’s age ≥12 months (1.84; 1.13−3.02). (4) Conclusion: FPS of intubation can be facilitated by deploying or developing clinically competent intubators, particularly for infants, in acute care settings.
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12
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Gan KH, Shepherd M. The adjuncts for endotracheal tube passage in simulated pediatric airways (AET‐SPA) study. J Am Coll Emerg Physicians Open 2022; 3:e12729. [PMID: 35505935 PMCID: PMC9051529 DOI: 10.1002/emp2.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives To investigate whether the use of adjuncts such as stylet, railroaded bougie, and preloaded bougie increases first‐pass success rate and decreases time to successful intubation when intubating simulated infant airways using direct laryngoscopy. Methods A crossover study using experienced practitioners (who were required to carry out emergency pediatric intubations as part of their usual practice) was completed. Participants completed a random sequence of 4 intubations in simulated “easy” airways and 4 intubations in simulated “difficult” airways, using naked endotracheal tube, stylet, railroaded bougie, and preloaded bougie on standardized infant airway manikins. First‐pass success rates and times to successful intubations were measured. Results From June 1 to December 30, 2019, 109 participants performed a total of 872 intubation attempts. In the easy airway, both naked endotracheal tube (mean 96.3% [95% confidence interval 90.9%–99.0%]) and stylet (mean 98.2% [95% confidence interval 93.5%–99.8%]) had higher first‐pass success rates than railroaded bougie and preloaded bougie. In the difficult airway, stylet (mean 76.1% [95% confidence interval 67.0%–83.8%]) had the highest first‐pass success rate, followed by the naked endotracheal tube, and then both the railroaded bougie and preloaded bougie. Differences in first‐pass success rates were independent of the participants’ numbers of previous pediatric intubations. Conclusion Results of this simulation‐based study suggest that stylet should be used as the first attempt technique for infant intubations regardless of the presence or absence of predicted airway difficulty. This finding needs further validation using alternative models and in non‐simulation settings.
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Affiliation(s)
- Khang Hee Gan
- Department of Emergency Starship Children's Hospital Grafton Auckland New Zealand
| | - Mike Shepherd
- Department of Emergency Starship Children's Hospital Grafton Auckland New Zealand
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Funakoshi H, Kunitani Y, Goto T, Okamoto H, Hagiwara Y, Watase H, Hasegawa K. Association Between Repeated Tracheal Intubation Attempts and Adverse Events in Children in the Emergency Department. Pediatr Emerg Care 2022; 38:e563-e568. [PMID: 35100759 DOI: 10.1097/pec.0000000000002356] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES Studies have shown that multiple intubation attempts are associated with a higher risk of intubation-related adverse events. However, little is known about the relationship in children in the emergency department (ED). METHODS This is an analysis of the data from 2 prospective, observational, multicenter registries of emergency airway management. The data were collected from consecutive patients who underwent emergency airway management in 19 EDs across Japan from March 2010 to November 2017. We included children 18 years or younger who underwent tracheal intubation in the ED. The primary exposure was the number of intubation attempts (1 vs ≥2). The primary outcome was an adverse event during or immediately after the intubation. RESULTS A total of 439 children were eligible for the analysis. Of 279 children with first-pass success, 24 children (9%) had an adverse event. By contrast, of 160 children with ≥2 intubation attempts, 50 children patients (31%) had an adverse event. In the unadjusted model, multiple intubation attempts were significantly associated with a higher rate of adverse events (unadjusted odds ratio, 4.83; 95% confidence interval, 2.57-9.06; P < 0.001). This association remained significant after adjusting for 7 potential confounders and patient clustering within the hospital (adjusted odds ratio, 4.49; 95% confidence interval, 2.36-8.53; P < 0.001). Similar associations were found across different age groups and among children without cardiac arrest (all, P < 0.05). CONCLUSIONS In this analysis of large prospective multicenter data, multiple intubation attempts were associated with a significantly higher rate of intubation-related adverse events in children in the ED.
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Affiliation(s)
- Hiraku Funakoshi
- From the Department of Emergency and Critical Care Medicine, Tokyobay Urayasu Ichikawa Medical Center, Chiba
| | - Yuri Kunitani
- From the Department of Emergency and Critical Care Medicine, Tokyobay Urayasu Ichikawa Medical Center, Chiba
| | - Tadahiro Goto
- Graduate School of Medical Sciences, University of Fukui, Fukui
| | - Hiroshi Okamoto
- Department of Critical Care Medicine, St. Luke's International Hospital
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, WA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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14
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Yamanaka S, Goto T, Morikawa K, Watase H, Okamoto H, Hagiwara Y, Hasegawa K. Machine Learning Approaches for Predicting Difficult Airway and First-Pass Success in the Emergency Department: Multicenter Prospective Observational Study. Interact J Med Res 2022; 11:e28366. [PMID: 35076398 PMCID: PMC8826144 DOI: 10.2196/28366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/07/2021] [Accepted: 12/06/2021] [Indexed: 12/13/2022] Open
Abstract
Background There is still room for improvement in the modified LEMON (look, evaluate, Mallampati, obstruction, neck mobility) criteria for difficult airway prediction and no prediction tool for first-pass success in the emergency department (ED). Objective We applied modern machine learning approaches to predict difficult airways and first-pass success. Methods In a multicenter prospective study that enrolled consecutive patients who underwent tracheal intubation in 13 EDs, we developed 7 machine learning models (eg, random forest model) using routinely collected data (eg, demographics, initial airway assessment). The outcomes were difficult airway and first-pass success. Model performance was evaluated using c-statistics, calibration slopes, and association measures (eg, sensitivity) in the test set (randomly selected 20% of the data). Their performance was compared with the modified LEMON criteria for difficult airway success and a logistic regression model for first-pass success. Results Of 10,741 patients who underwent intubation, 543 patients (5.1%) had a difficult airway, and 7690 patients (71.6%) had first-pass success. In predicting a difficult airway, machine learning models—except for k-point nearest neighbor and multilayer perceptron—had higher discrimination ability than the modified LEMON criteria (all, P≤.001). For example, the ensemble method had the highest c-statistic (0.74 vs 0.62 with the modified LEMON criteria; P<.001). Machine learning models—except k-point nearest neighbor and random forest models—had higher discrimination ability for first-pass success. In particular, the ensemble model had the highest c-statistic (0.81 vs 0.76 with the reference regression; P<.001). Conclusions Machine learning models demonstrated greater ability for predicting difficult airway and first-pass success in the ED.
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Affiliation(s)
- Syunsuke Yamanaka
- Department of Emergency Medicine & General Internal Medicine, The University of Fukui, Fukui, Japan
| | - Tadahiro Goto
- Department of Clinical Epidemiology & Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | | | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, WA, United States
| | - Hiroshi Okamoto
- Department of Intensive Care, St. Luke's International Hospital, Tokyo, Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
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15
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Harris M, Lyng JW, Mandt M, Moore B, Gross T, Gausche-Hill M, Donofrio-Odmann JJ. Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:118-128. [PMID: 35001823 DOI: 10.1080/10903127.2021.1994675] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.
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16
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Pokrajac N, Sbiroli E, Hollenbach KA, Kohn MA, Contreras E, Murray M. Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e126-e131. [PMID: 32576791 DOI: 10.1097/pec.0000000000002171] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiac arrest is a significant complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies have evaluated risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) setting. This study identified risk factors for PICA among patients undergoing emergent ETI in a pediatric ED. METHODS We performed a nested case-control study within the cohort of children who underwent emergent ETI in our pediatric ED during a 9-year period. Cases were children with PICA within 20 minutes of ETI. Controls (4 per case) were randomly selected children without PICA after ETI. We analyzed potential risk factors based on published data and physiologic plausibility and created a simple risk model using univariate results, model fit statistics, and clinical judgment. RESULTS In the cohort of patients undergoing ETI, PICA occurred in 21 of 543 subjects (3.9%; 95% confidence interval [CI], 2.2-5.9%), with return of spontaneous circulation in 16 of 21 (76.2%; 95% CI, 52.8-91.8%) and survival to discharge in 12 of 21 (57.1%; 95% CI, 34.0-78.2%). On univariate analysis, cases were more likely to be younger, have delayed capillary refill time, systolic or diastolic hypotension, hypoxia, greater than one intubation attempt, no sedative or paralytic used, and pulmonary disease compared with controls. Our 4-category risk model for PICA combined preintubation hypoxia (or an unobtainable pulse oximetry value) and younger than 1 year. The area under the receiver operating characteristic curve for this model was 0.87 (95% CI, 0.77-0.97). CONCLUSIONS Hypoxia (or an unobtainable pulse oximetry value) was the strongest predictor for PICA among children after emergent ETI in our sample. A simple risk model combining pre-ETI hypoxia and younger than 1 year showed excellent discrimination in this sample. Our results require independent validation.
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Affiliation(s)
- Nicholas Pokrajac
- From the Department of Emergency Medicine, Stanford University School of Medicine
| | - Emily Sbiroli
- Department of Emergency Medicine, UC San Diego Health System
| | - Kathryn A Hollenbach
- Division of Emergency Medicine, Department of Pediatrics, UC San Diego Health System and Rady Children's Hospital
| | - Michael A Kohn
- From the Department of Emergency Medicine, Stanford University School of Medicine
| | - Edwin Contreras
- Department of Emergency Medicine, Kaiser Permanente San Diego, San Diego, CA
| | - Matthew Murray
- Department of Emergency Medicine, UC San Diego Health System
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17
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Elonheimo L, Ljungqvist H, Harve‐Rytsälä H, Jäntti H, Nurmi J. Frequency, indications and success of out-of-hospital intubations in Finnish children. Acta Anaesthesiol Scand 2022; 66:125-131. [PMID: 34514584 DOI: 10.1111/aas.13980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Earlier studies have shown variable results regarding the success of paediatric emergency endotracheal intubation between different settings and operators. We aimed to describe the paediatric population intubated by physician-staffed helicopter emergency medical service (HEMS) and evaluate the factors associated with overall and first-pass success (FPS). METHODS We conducted a retrospective observational cohort study in Finland including all children less than 16 years old who required endotracheal intubation by a HEMS physician from January 2014 to August 2019. Utilising a national HEMS database, we analysed the incidence, indications, overall and first-pass success rates of endotracheal intubation. RESULTS A total of 2731 children were encountered by HEMS, and intubation was attempted in 245 (9%); of these, 22 were younger than 1 year, 103 were aged 1-5 years and 120 were aged 6-15 years. The most common indications for airway management were cardiac arrest for the youngest age group, neurological reasons (e.g., seizures) for those aged 1-5 years and trauma for those aged 6-15. The HEMS physicians had an overall success rate of 100% (95% CI: 98-100) and an FPS rate of 86% (95% CI: 82-90). The FPS rate was lower in the youngest age group (p = .002) and for patients in cardiac arrest (p < .001). CONCLUSIONS Emergency endotracheal intubation of children is successfully performed by a physician staffed HEMS unit even though these procedures are rare. To improve the care, emphasis should be on airway management of infants and patients in cardiac arrest.
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Affiliation(s)
- Lauri Elonheimo
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
| | | | - Heini Harve‐Rytsälä
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
| | - Helena Jäntti
- Center for Prehospital Emergency Care Kuopio University Hospital Kuopio Finland
| | - Jouni Nurmi
- Emergency Medicine and Services Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
- FinnHEMS Research and Development Unit Vantaa Finland
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18
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Pacheco GS, Patanwala AE, Mendelson JS, Sakles JC. Clinical Experience With the C-MAC and GlideScope in a Pediatric Emergency Department Over a 10-Year Period. Pediatr Emerg Care 2021; 37:e1098-e1103. [PMID: 31503130 DOI: 10.1097/pec.0000000000001911] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is little literature describing the performance of video laryngoscopes for the intubation of pediatric patients in the emergency department (ED). The purpose of this study is to report our experience with direct laryngoscopy (DL), the C-MAC (CMAC), and the GlideScope (GVL) over a 10-year period in an urban academic pediatric ED. METHODS This was an analysis of pediatric intubations prospectively recorded into a Continuous Quality Improvement database in an academic pediatric ED over a 10-year period. Between July 1, 2007, and June 30, 2017, emergency physicians recorded all consecutive intubations performed in the pediatric ED. The database included patient demographics and detailed information on each intubation such as age of the patient, reason for intubation, device(s) used, method of intubation, difficult airway characteristics, adverse events, number of intubation attempts, and outcome of each attempt. All patients younger than 18 years who underwent intubation by an emergency medicine resident using a DL or videolaryngoscope (CMAC or GVL) were included in the study. The primary outcome measure was first-pass success without adverse events (FPS-AE), which was defined as successful tracheal intubation on a single laryngoscope insertion without the occurrence of any adverse events during the peri-intubation period. A multivariate regression analysis was performed to control for potential confounders and included difficult airway characteristic, operator level of training, method of intubation, and patient age. RESULTS During the study period, 530 intubations were performed in pediatric patients. Of these, 493 intubations met the inclusion criteria and were analyzed (218 DL, 187 CMAC, 88 GVL). The FPS-AE with each device is as follows: DL, 54.1% (n = 118/218); CMAC, 64.0% (n = 119/187); and GVL, 52.3% (n = 46/88). In the logistic regression analysis, compared with DL, the CMAC was associated with a higher FPS-AE (odds ratio, 1.6 [95% confidence interval, 1.03-2.45]), whereas the GVL was not associated with an increased FPS-AE (odds ratio, 0.62 [95% confidence interval, 0.35-1.10]). CONCLUSIONS In this study of pediatric patients intubated in the ED, compared with DL, the CMAC was associated with an increased FPS-AE, but the GVL was not.
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Affiliation(s)
- Garrett S Pacheco
- From the Departments of Emergency Medicine and Pediatrics, University of Arizona College of Medicine, Banner University Medical Center Tucson, Tucson, AZ
| | - Asad E Patanwala
- The University of Sydney School of Pharmacy|Royal Prince Alfred Hospital, 1Faculty of Medicine and Health|The University of Sydney|NSW, Sydney, Australia
| | | | - John C Sakles
- Department of Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ
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19
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Manrique G, Pérez G, Butragueño-Laiseca L, García M, Slöcker M, González R, Herrera L, Mencía S, Del Castillo J, Solana MJ, Sanz D, Cieza R, Fernández SN, López J, Urbano J, López-Herce J. Effects of airway management and tidal volume feedback ventilation during pediatric resuscitation in piglets with asphyxial cardiac arrest. Sci Rep 2021; 11:16138. [PMID: 34373497 PMCID: PMC8352976 DOI: 10.1038/s41598-021-95296-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 07/20/2021] [Indexed: 11/09/2022] Open
Abstract
To compare the effect on the recovery of spontaneous circulation (ROSC) of early endotracheal intubation (ETI) versus bag-mask ventilation (BMV), and expiratory real-time tidal volume (VTe) feedback (TVF) ventilation versus without feedback or standard ventilation (SV) in a pediatric animal model of asphyxial cardiac arrest. Piglets were randomized into five groups: 1: ETI and TVF ventilation (10 ml/kg); 2: ETI and TVF (7 ml/kg); 3: ETI and SV; 4: BMV and TVF (10 ml/kg) and 5: BMV and SV. Thirty breaths-per-minute guided by metronome were given. ROSC, pCO2, pO2, EtCO2 and VTe were compared among groups. Seventy-nine piglets (11.3 ± 1.2 kg) were included. Twenty-six (32.9%) achieved ROSC. Survival was non-significantly higher in ETI (40.4%) than BMV groups (21.9%), p = 0.08. No differences in ROSC were found between TVF and SV groups (30.0% versus 34.7%, p = 0.67). ETI groups presented lower pCO2, and higher pO2, EtCO2 and VTe than BMV groups (p < 0.05). VTe was lower in TVF than in SV groups and in BMV than in ETI groups (p < 0.05). Groups 1 and 3 showed higher pO2 and lower pCO2 over time, although with hyperventilation values (pCO2 < 35 mmHg). ETI groups had non significantly higher survival rate than BMV groups. Compared to BMV groups, ETI groups achieved better oxygenation and ventilation parameters. VTe was lower in both TVF and BMV groups. Hyperventilation was observed in intubated animals with SV and with 10 ml/kg VTF.
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Affiliation(s)
- Gema Manrique
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Gema Pérez
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Laura Butragueño-Laiseca
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Miriam García
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - María Slöcker
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Rafael González
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Laura Herrera
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - Santiago Mencía
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Jimena Del Castillo
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - María José Solana
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Débora Sanz
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - Raquel Cieza
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
| | - Sarah N Fernández
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Jorge López
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain
| | - Javier Urbano
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain.
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain.
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid, Madrid, Spain.
| | - Jesús López-Herce
- Pediatric Intensive Care Department, Hospital General Universitario Gregorio Marañón, Dr Castelo 47, 28009, Madrid, Spain.
- Health Research Institute of the Gregorio Marañón Hospital, Madrid, Spain.
- Research Network on Maternal and Child Health and Development (RedSAMID), Madrid, Spain.
- Maternal and Child Public Health Department. School of Medicine, Complutense University of Madrid, Madrid, Spain.
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20
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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To YH, Ong YKG, Chong SL, Ang PH, Bte Zakaria ND, Lee KP, Pek JH. Differences in intubation outcomes for pediatric patients between pediatric and general Emergency Departments. Paediatr Anaesth 2021; 31:713-719. [PMID: 33774880 DOI: 10.1111/pan.14185] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/26/2021] [Accepted: 03/22/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intubation is a life-saving intervention at the Emergency Department (ED). However, general and pediatric EDs may vary in their preparedness to manage children with airway emergencies. AIMS We aimed to compare rates of first-pass intubation and adverse tracheal intubation-associated events between general and pediatric EDs. METHODS A retrospective review of medical records was conducted at a pediatric ED and three general EDs from January 1, 2015, to December 31, 2018. Information about the intubation process involving pediatric patients (less than 16 years old), as well as eventual outcomes of first-pass intubation and adverse tracheal intubation-associated events were collected and analyzed. RESULTS There were 180 pediatric intubations, of which 115 (63.9%) were performed in pediatric ED. The median age was 2 years old (interquartile range 0-6). Intubation was most commonly performed for patients with cardiac arrest (88, 48.9%). Direct laryngoscopy was used in 178 (98.9%) cases and uncuffed tube was used in 135 (75.0%) cases. Apneic oxygenation was performed in 26 (14.4%) cases-all in pediatric ED. Intubation was predominantly performed by senior clinicians (162, 90.0%). Overall, intubation was performed successfully in 175 (97.2%) cases, with a first-pass intubation rate of 82.2% which was similar between pediatric (96, 83.5%) and general EDs (52, 80%) (Odds ratio [OR] 1.26, 95% confidence interval [CI] 0.58 to 2.76, p = .558). There were 68 adverse tracheal intubation-associated events with right mainstem intubation being the most common (23, 12.8%). Pediatric EDs (44, 38.3%) had a higher rate of adverse tracheal intubation-associated events than general EDs (15, 23.1%) (OR 2.07, 95% CI 1.04 to 4.11; p = .037). CONCLUSIONS Differences exist in intubation outcomes between pediatric and general EDs. Quality improvement efforts should focus on standardizing intubation practices across both pediatric and general EDs.
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Affiliation(s)
- Yi Hui To
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Peck Har Ang
- Accident & Emergency Department, Changi General Hospital, SingHealth, Singapore City, Singapore
| | - Nur Diana Bte Zakaria
- Department of Emergency Medicine, Singapore General Hospital, SingHealth, Singapore City, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, SingHealth, Singapore City, Singapore
| | - Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, SingHealth, Singapore City, Singapore
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22
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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23
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Campbell BR, Shinn JR, Kimura KS, Lowery AS, Casey JD, Ely EW, Gelbard A. Unilateral Vocal Fold Immobility After Prolonged Endotracheal Intubation. JAMA Otolaryngol Head Neck Surg 2021; 146:160-167. [PMID: 31855261 DOI: 10.1001/jamaoto.2019.3969] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance Endotracheal intubation and mechanical ventilation are life-saving treatments for acute respiratory failure but are complicated by significant rates of dyspnea and dysphonia after extubation. Unilateral vocal fold immobility (UVFI) after extubation can alter respiration and phonation, but its incidence, risk factors, and pathophysiology remain unclear. Objectives To determine the incidence of UVFI after prolonged (>12 hours) mechanical ventilation in a medical intensive care unit and investigate associated clinical risk factors for UVFI after prolonged mechanical ventilation. Design, Setting, and Participants This subgroup analysis of a prospective cohort study was conducted in a single-center medical intensive care unit from August 17, 2017, through May 31, 2018, among 100 consecutive adult patients who were intubated for more than 12 hours. Patients were identified within 36 hours of extubation and recruited for study enrollment. Those with an established tracheostomy prior to mechanical ventilation, known laryngeal or tracheal pathologic characteristics, or a history of head and neck radiotherapy were excluded. Exposure Invasive mechanical ventilation via an endotracheal tube. Main Outcomes and Measures The incidence of UVFI as determined by flexible nasolaryngoscopy. Results One hundred patients (62 men [62%]; median age, 58.5 years [range, 19.0-87.0 years]) underwent endoscopic evaluation after extubation. Seven patients had UVFI, of which 6 cases (86%) were left sided. Patients with hypotension while intubated (odds ratio [OR], 10.8; 95% CI, 1.6 to ∞), patients requiring vasopressors while intubated (OR, 16.7; 95% CI, 2.4 to ∞), and patients with a preadmission diagnosis of peripheral vascular disease (OR, 6.2; 95% CI, 1.2-31.9) or coronary artery disease (OR, 5.1; 95% CI, 1.0-25.5) were more likely to develop UVFI. Conclusions and Relevance Unilateral vocal fold immobility occurred in 7 of 100 patients in the medical intensive care unit who were intubated for more than 12 hours. Unilateral vocal fold immobility was associated with inpatient hypotension and preadmission vascular disease, suggesting that ischemia of the recurrent laryngeal nerve may play a role in disease pathogenesis.
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Affiliation(s)
- Benjamin R Campbell
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kyle S Kimura
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anne S Lowery
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E Wesley Ely
- Tennessee Valley Veteran's Affairs Geriatric Research Education and Clinical Center, Nashville.,Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University, Nashville, Tennessee
| | - Alexander Gelbard
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Laryngology, Vanderbilt University Medical Center, Nashville, Tennessee
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24
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Couto TB, Reis AG, Farhat SCL, Carvalho VEL, Schvartsman C. Changing the view: impact of simulation-based mastery learning in pediatric tracheal intubation with videolaryngoscopy. J Pediatr (Rio J) 2021; 97:30-36. [PMID: 32156536 PMCID: PMC9432116 DOI: 10.1016/j.jped.2019.12.007] [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: 11/13/2019] [Revised: 12/22/2019] [Accepted: 12/26/2019] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE To determine the effect of a training program using simulation-based mastery learning on the performance of residents in pediatric intubations with videolaryngoscopy. METHOD Retrospective cohort study carried out in a tertiary pediatric hospital between July 2016 and June 2018 evaluating a database that included the performance of residents before and after training, as well as the outcome of tracheal intubations. A total of 59 pediatric residents were evaluated in the pre-training with a skills' checklist in the scenario with an intubation simulator; subsequently, they were trained individually using a simulator and deliberate practice in the department itself. After training, the residents were expected to have a minimum passing grade (90/100) in a simulated scenario. The success of the first attempted intubation, use of videolaryngoscopy, and complications in patients older than 1year of age during the study period were also recorded in clinical practice. RESULTS Before training, the mean grade was 77.5/100 (SD 15.2), with only 23.7% (14/59) of residents reaching the minimum passing grade of 90/100. After training, 100% of the residents reached the grade, with an average of 94.9/100 (SD 3.2), p<0.01, with only 5.1% (3/59) needing more practice time than that initially allocated. The success rate in the first attempt at intubation in the emergency department with videolaryngoscopy was 77.8% (21/27). The rate of adverse events associated with intubations was 26% (7/27), representing a serious event. CONCLUSIONS Simulation-based mastery learning increased residents' skills related to intubation and allowed safe tracheal intubations with video laryngoscopy.
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Affiliation(s)
- Thomaz Bittencourt Couto
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil.
| | - Amélia G Reis
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Sylvia C L Farhat
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Vitor E L Carvalho
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Claudio Schvartsman
- Universidade de São Paulo, Faculdade de Medicina, Instituto da Criança, Hospital das Clínicas, São Paulo, SP, Brazil
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25
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Couto TB, Reis AG, Farhat SCL, Carvalho VEDL, Schvartsman C. Changing the view: Video versus direct laryngoscopy for intubation in the pediatric emergency department. Medicine (Baltimore) 2020; 99:e22289. [PMID: 32957386 PMCID: PMC7505323 DOI: 10.1097/md.0000000000022289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The aim of this study was to compare the success of first-attempt tracheal intubation in pediatric patients >1-year old performed using video versus direct laryngoscopy and compare the frequency of tracheal intubation-associated events and desaturation among these patients.Prospective observational cohort study conducted in an Academic pediatric tertiary emergency department. We compared 50 children intubated with Mcgrath Mac video laryngoscope (VL group) and an historical series of 141 children intubated with direct laryngoscopy (DL group). All patients were aged 1 to 18 years.The first attempt success rates were 68% (34/50) and 37.6% (53/141) in the VL and DL groups (P < .01), respectively. There was a lower proportion of tracheal intubation-associated events in the VL group (VL, 31.3% [15/50] vs DL, 67.8% [97/141]; P < .01) and no significant differences in desaturation (VL, 35% [14/50] vs DL 51.8% [72/141]; P = .06). The median number of attempts was 1 (range, 1-5) for the VL group and 2 (range, 1-8) for the DL group (P < .01). Multivariate logistic regression showed that video laryngoscope use was associated with higher chances of first-attempt intubation with an odds ratio of 4.5 (95% confidence interval, 1.9-10.4, P < 0.01).Compared with direct laryngoscopy, VL was associated with higher success rates of first-attempt tracheal intubations and lower rates of tracheal intubation-associated events.
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26
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Kaji AH, Shover C, Lee J, Yee L, Pallin DJ, April MD, Carlson JN, Fantegrossi A, Brown CA. Video Versus Direct and Augmented Direct Laryngoscopy in Pediatric Tracheal Intubations. Acad Emerg Med 2020; 27:394-402. [PMID: 31617640 DOI: 10.1111/acem.13869] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/25/2019] [Accepted: 10/13/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES With respect to first-attempt intubation success, the pediatric literature demonstrates either clinical equipoise or superiority of direct laryngoscopy (DL) when compared to video laryngoscopy (VL). Furthermore, it is unknown how VL compares to DL, when DL is "augmented" by maneuvers, such as optimal external laryngeal manipulation (OELM), upright or ramped positioning, or the use of the bougie. The objective of our study was to compare first-attempt success between VL and all DL, including "augmented DL" for pediatric intubations. METHODS We analyzed the National Emergency Airway Registry database of intubations of patients < 16 years. Variables collected included patient demographics, body habitus, impression of airway difficulty, intubating position, reduced neck mobility, airway characteristics, device, medications, and operator characteristics, adjusted for clustering by center. Primary outcome was the difference in first-attempt success for DL and augmented DL versus VL. Secondary outcomes included adverse events. In a planned sensitivity analysis, a propensity-adjusted analysis for first-attempt success and a subgroup analysis of children < 2 years was also performed. RESULTS Of 625 analyzable pediatric encounters, 294 (47.0%, 95% confidence interval [CI] = 25.1% to 69.0%) were DL; 332 (53.1%, 95% CI = 31.0% to 74.9%) were VL. Median age was 4 years (interquartile range = 1 to 10 years); 225 (36.0%, 95% CI = 30.8% to 41.2%) were < 2 years. Overall first-pass success was 79.6% (95% CI = 74.1% to 84.9%). VL first-pass success was 278/331 (84.0%) versus 219/294 for DL (74.5%), adjusted for clustering (odds ratio [OR] = 1.7, 95% CI = 1.3 to 2.5). Multivariable regression showed that VL yielded a higher odds of first-attempt success than DL augmented by OELM or use of a bougie (adjusted OR = 5.5, 95% CI = 1.7 to 18.1). Propensity-adjusted analyses supported the main results. Subgroup analysis of age < 2 years also demonstrated VL superiority (OR = 2.0, 95% CI = 1.1 to 3.3) compared with DL. Adverse events were comparable in both univariate and multivariable analysis. CONCLUSIONS When compared to DL, VL was associated with higher first-pass success in this pediatric population, even in the subgroup of patients < 2 years, as well as when DL was augmented. There were no differences in adverse effects between DL and VL.
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Affiliation(s)
- Amy H. Kaji
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Carolyn Shover
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Jennifer Lee
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Lisa Yee
- Department of Emergency Medicine Harbor–University of California Los Angeles Medical Center Torrance CA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston MA
| | - Michael D. April
- Department of Emergency Medicine San Antonio Uniformed Services Health Education Consortium (SAUSHEC) Fort Sam Houston TX
| | - Jestin N. Carlson
- Department of Emergency Medicine St. Vincent Hospital Allegheny Health Network Erie PA
| | - Andrea Fantegrossi
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston MA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women’s Hospital Harvard Medical School Boston MA
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Ramgopal S, Button SE, Owusu-Ansah S, Manole MD, Saladino RA, Guyette FX, Martin-Gill C. Success of Pediatric Intubations Performed by a Critical Care Transport Service. PREHOSP EMERG CARE 2020; 24:683-692. [PMID: 31800336 DOI: 10.1080/10903127.2019.1699212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Prehospital pediatric endotracheal intubation (ETI) is rarely performed. Previous research has suggested that pediatric prehospital ETI, when performed by ground advanced life support crews, is associated with poor outcomes. In this study, we aim to evaluate the first-attempt success rate, overall success rate and complications of pediatric prehospital ETI performed by critical care transport (CCT) personnel.Methods: We conducted a retrospective observational study in a multi-state CCT service performing rotor wing, ground, and fixed wing missions. We included pediatric patients (<18 years) for whom ETI was performed by CCT personnel (flight nurse or flight paramedic).Our primary outcome of interest was rate of first-attempt ETI. Secondary outcomes were overall rates of successful ETI, complications encountered, and outcomes of patients with unsuccessful intubation.Results: 993 patients were included (63.2% male, median age 12 years, IQR 4-16 years). 807/993 (81.3%) patients were intubated on the first attempt. Lower rates of successful first-attempt intubation were seen in younger ages (42.9% in infants ≤30 days of age). In multivariable logistic regression, lower odds (adjusted odds ratio, 95% confidence interval) of successful first-attempt ETI were associated with ages >30 days to <1 year (0.33, 0.18-0.61) and 2 to <6 years (0.60, 0.39-0.94) compared to patients 12 to <18 years. Patients given an induction agent and neuromuscular blockade (NMB) had a higher odds of first-attempt ETI success (1.53, 1.06-2.15). 13 (1.3%) had immediately recognized esophageal intubation and 33 (3.3%) had vomiting. No episodes of pneumothorax were reported. 962/993 (96.9%) patients were successfully intubated after all attempts. In patients without successful ETI (n = 31), supraglottic airways were used in 24, bag-valve mask ventilation in 5, and surgical cricothyroidotomy in 2, with an overall advanced airway success rate of 988/993 (99.5%).Conclusion: Critical care flight nurses and paramedics performed successful intubations in pediatric patients at a high rate of success. Younger age was associated with lower success rates. Improved ETI training for younger patients and use of an induction agent and NMB may improve airway management in critically ill children.
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28
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Tanya S, Dubrowski A. Development of a Cost-Effective Pediatric Intubation Task Trainer for Rural Medical Education. Cureus 2020; 12:e6604. [PMID: 32064186 PMCID: PMC7008755 DOI: 10.7759/cureus.6604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Pediatric intubation and airway management (PIAM) is a life-saving, emergent procedure that is performed by a variety of healthcare practitioners. Securing the pediatric airway in a time-sensitive fashion is a specialized skill that declines with lack of practice, leading to a precarious gap in clinical competency and healthcare delivery. However, current training models for PIAM, such as live animals, human cadavers, and simulators, are not adequately accessible or reliable due to their combination of high cost, unrealistic simulation, lack of standardization, and ethical concerns. Task trainers pose an ethically and fiscally sustainable training model for experiential learning through repetitive practice, which has been shown to dramatically improve trainee proficiency and confidence in performing high-acuity low-occurrence procedures such as pediatric intubation. This work aims to report the development process and initial validation evidence of a prototype cost-effective pediatric intubation task trainer that can be used for post-graduate education, especially in resource-challenged settings.
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Affiliation(s)
- Stuti Tanya
- Medical Education and Simulation, Memorial University of Newfoundland, St. John's, CAN
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29
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Ghedina N, Alkhouri H, Badge H, Fogg T, McCarthy S. Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR. Emerg Med Australas 2019; 32:401-408. [DOI: 10.1111/1742-6723.13416] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Nicole Ghedina
- Emergency DepartmentSt John of God Midland Public Hospital Perth Western Australia Australia
- Royal Flying Doctor Service Western Operations Perth Western Australia Australia
| | - Hatem Alkhouri
- Agency for Clinical InnovationEmergency Care Institute Sydney New South Wales Australia
- Faculty of MedicineThe University of New South Wales Sydney New South Wales Australia
| | - Helen Badge
- Agency for Clinical InnovationEmergency Care Institute Sydney New South Wales Australia
- Faculty of MedicineThe University of New South Wales Sydney New South Wales Australia
| | - Toby Fogg
- Emergency DepartmentRoyal North Shore Hospital Sydney New South Wales Australia
- CareFlight/NSW Ambulance Service Sydney New South Wales Australia
| | - Sally McCarthy
- Emergency DepartmentPrince of Wales Hospital Sydney New South Wales Australia
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30
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Association of ketamine use with lower risks of post-intubation hypotension in hemodynamically-unstable patients in the emergency department. Sci Rep 2019; 9:17230. [PMID: 31754159 PMCID: PMC6872717 DOI: 10.1038/s41598-019-53360-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 09/09/2019] [Indexed: 12/16/2022] Open
Abstract
To determine whether ketamine use for tracheal intubation, compared to other sedative use, is associated with a lower risk of post-intubation hypotension in hemodynamically-unstable patients in the emergency department (ED), we analyzed the data of a prospective, multicenter, observational study-the second Japanese Emergency Airway Network (JEAN-2) Study-from February 2012 through November 2017. The current analysis included adult non-cardiac-arrest ED patients with a pre-intubation shock index of ≥0.9. The primary exposure was ketamine use as a sedative for intubation, with midazolam or propofol use as the reference. The primary outcome was post-intubation hypotension. A total of 977 patients was included in the current analysis. Overall, 24% of patients developed post-intubation hypotension. The ketamine group had a lower risk of post-intubation hypotension compared to the reference group (15% vs 29%, unadjusted odds ratio [OR] 0.45 [95% CI 0.31-0.66] p < 0.001). This association remained significant in the multivariable analysis (adjusted OR 0.43 [95% CI 0.28-0.64] p < 0.001). Likewise, in the propensity-score matching analysis, the patients with ketamine use also had a significantly lower risk of post-intubation hypotension (OR 0.47 [95% CI, 0.31-0.71] P < 0.001). Our observations support ketamine use as a safe sedative agent for intubation in hemodynamically-unstable patients in the ED.
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31
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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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Jiang L, Qiu S, Zhang P, Yao W, Chang Y, Dai Z. The midline approach for endotracheal intubation using GlideScope video laryngoscopy could provide better glottis exposure in adults: a randomized controlled trial. BMC Anesthesiol 2019; 19:200. [PMID: 31690285 PMCID: PMC6829853 DOI: 10.1186/s12871-019-0876-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/24/2019] [Indexed: 11/13/2022] Open
Abstract
Background Previous studies have demonstrated that the common laryngoscopic approach (right-sided) and midline approach are both used for endotracheal intubation by direct laryngoscopy. Although the midline approach is commonly recommended for video laryngoscopy (VL) in the clinic, there is a lack of published evidences to support this practice. This study aimed to evaluate the effects of different video laryngoscopic approaches on intubation. Methods Two hundred sixty-two patients aged 18 years who underwent elective surgery under general anaesthesia and required endotracheal intubation were included in the present prospective, randomized, controlled study. The participants were randomly and equally allocated to the right approach (Group R) or midline approach (Group M). All the intubations were conducted by experienced anaesthetists using GlideScope video laryngoscopy. The primary outcomes were Cormack-Lehane laryngoscopic views (CLVs) and first-pass success (FPS) rates. The secondary outcomes were the time to glottis exposure, time to tracheal intubation, haemodynamic responses and other adverse events. Comparative analysis was performed between the groups. Results Finally, 262 patients completed the study, and all the tracheas were successfully intubated. No significant differences were observed in the patient characteristics and airway assessments (P > 0.05). Compared with Group R, Group M had a better CLV (χ2 = 14.706, P = 0.001) and shorter times to glottis exposure (8.82 ± 2.04 vs 12.38 ± 1.81; t = 14.94; P < 0.001) and tracheal intubation (37.19 ± 5.01 vs 45.23 ± 4.81; t = 13.25; P < 0.001), but no difference was found in the FPS rate (70.2% vs 71.8%; χ2 = 0.074; P = 0.446) and intubation procedure time (29.86 ± 2.56 vs 30.46 ± 2.97, t = 1.75, P = 0.081). Between the groups, the rates of hoarseness or sore throat, minor injury, hypoxemia and changes in SBP and HR showed no significant difference (P > 0.05). Conclusion Although the FPS rate did not differ based on the laryngoscopic approach, the midline approach could provide better glottis exposure and shorter times to glottis exposure and intubation. The midline approach should be recommended for teaching in VL-assisted endotracheal intubation. Trial registration The study was registered on May 18, 2019 in the Chinese Clinical Trial Registry (ChiCTR1900023252).
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Affiliation(s)
- Lianxiang Jiang
- Department of Anaesthesia, Yijishan Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu City, Anhui Province, China
| | - Shulin Qiu
- Department of Anaesthesia, Beijing Tiantan Hospital of Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Anaesthesia, Yijishan Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu City, Anhui Province, China
| | - Weidong Yao
- Department of Anaesthesia, Yijishan Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu City, Anhui Province, China
| | - Yan Chang
- Department of Anaesthesia, Yijishan Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu City, Anhui Province, China
| | - Zeping Dai
- Department of Anaesthesia, Yijishan Hospital of Wannan Medical College, No. 2, Zheshan West Road, Wuhu City, Anhui Province, China.
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Mori T, Nomura O, Hagiwara Y, Inoue N. Diagnostic Accuracy of a 3-Point Ultrasound Protocol to Detect Esophageal or Endobronchial Mainstem Intubation in a Pediatric Emergency Department. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2945-2954. [PMID: 30993739 DOI: 10.1002/jum.15000] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/25/2019] [Accepted: 03/01/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the diagnostic accuracy of the 3-point approach with ultrasonography for confirming endotracheal tube (ETT) placement in pediatric patients. METHODS This was a prospective study conducted at a tertiary care center in Japan between March 2014 and March 2016. Children aged 0 to 18 years requiring endotracheal intubation in our emergency department (ED) who underwent ultrasonography for confirming ETT placement were enrolled. Patients who had already undergone a tracheotomy or intubation before arrival at our ED or who had severe neck injuries hindering ultrasonography were excluded. Quantitative capnography and portable chest x-ray imaging were used as the reference standard for the confirmation of proper ETT placement. The main outcome was the diagnostic accuracy of the 3-point approach with ultrasonography for detecting inappropriate ETT placement. RESULTS In total, 68 patients were enrolled. The median age was 17 months (interquartile range, 8-40), and 51.4% were males. Three (4.4%) and 7 (10.3%) patients had esophageal and endobronchial mainstem intubation, respectively. The patients received emergency intubation due to a dysfunction of the central nervous system (45.6%) or respiratory failure (22.0%). The sensitivity and specificity of esophageal versus tracheal intubation was 100% (95% confidence interval [CI], 54.9%-100.0%) and 100% (95% CI, 97.9%-100.0%), respectively, whereas for endobronchial mainstem intubation versus tracheal intubation, the sensitivity and specificity was 85.7% (95% CI, 56.7%-96.0%) and 98.3% (95% CI, 94.8%-99.5%), respectively. Agreement between the reviewers was high (kappa coefficient, 0.78). CONCLUSION The 3-point approach with ultrasonography was a feasible method for detecting esophageal and endobronchial mainstem intubation in pediatric patients.
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Affiliation(s)
- Takaaki Mori
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Osamu Nomura
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yusuke Hagiwara
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Nobuaki Inoue
- Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
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Goto T, Goto Y, Hagiwara Y, Okamoto H, Watase H, Hasegawa K. Advancing emergency airway management practice and research. Acute Med Surg 2019; 6:336-351. [PMID: 31592072 PMCID: PMC6773646 DOI: 10.1002/ams2.428] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022] Open
Abstract
Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.
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Affiliation(s)
- Tadahiro Goto
- Graduate School of Medical Sciences University of Fukui Fukui Japan
| | - Yukari Goto
- Department of Emergency and Critical Care Nagoya University Hospital Nagoya Aichi Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine Tokyo Metropolitan Children's Medical Centre Fuchu Tokyo Japan
| | - Hiroshi Okamoto
- Department of Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Hiroko Watase
- Department of Surgery University of Washington Seattle Washington
| | - Kohei Hasegawa
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts
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Inoue A, Okamoto H, Hifumi T, Goto T, Hagiwara Y, Watase H, Hasegawa K. The incidence of post-intubation hypertension and association with repeated intubation attempts in the emergency department. PLoS One 2019; 14:e0212170. [PMID: 30742676 PMCID: PMC6370241 DOI: 10.1371/journal.pone.0212170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 01/29/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Studies in the non-emergency department (ED) settings have reported the relationships of post-intubation hypertension with poor patient outcomes. While ED-based studies have examined post-intubation hypotension and its sequelae, little is known about, post-intubation hypertension and its risk factors in the ED settings. In this context, we aimed to identify the incidence of post-intubation hypertension in the ED, and to test the hypothesis that repeated intubation attempts are associated with an increased risk of post-intubation hypertension. METHODS This study is a secondary analysis of the data from a multicenter prospective observational study of emergency intubations in 15 EDs from 2012 through 2016. The analytic cohort comprised all adult non-cardiac-arrest patients undergoing orotracheal intubation without pre-intubation hypotension. The primary exposure was the repeated intubation attempts, defined as ≥2 laryngoscopic attempts. The outcome was post-intubation hypertension defined as an increase in systolic blood pressure (sBP) of >20% along with a post-intubation sBP of >160 mmHg. To investigate the association of repeated intubation attempts with the risk of post-intubation hypertension, we fit multivariable logistic regression models adjusting for ten potential confounders and patient clustering within the EDs. RESULTS Of 3,097 patients, the median age was 69 years, 1,977 (64.0%) were men, and 991 (32.0%) underwent repeated intubation attempts. Post-intubation hypertension was observed in 276 (8.9%). In the unadjusted model, the incidence of post-intubation hypertension did not differ between the patients with single intubation attempt and those with repeated attempts (8.5% versus 9.8%, unadjusted P = 0.24). By contrast, after adjusting for potential confounders and patient clustering in the random-effects model, the patients who underwent repeated intubation attempts had a significantly higher risk of post-intubation hypertension (OR, 1.56; 95% CI, 1.11-2.18; adjusted P = 0.01). CONCLUSIONS We found that 8.9% of patients developed post-intubation hypertension, and that repeated intubation attempts were significantly associated with a significantly higher risk of post-intubation hypertension in the ED.
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Affiliation(s)
- Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Miki, Kita, Kagawa, Japan
- * E-mail:
| | - Hiroshi Okamoto
- Center for Clinical Epidemiology, St. Luke’s International University, Chuo-ku, Tokyo, Japan
| | - Toru Hifumi
- Emergency and Critical Care medicine, St. Luke's International Hospital, Chuo-ku, Tokyo, Japan
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Hiroko Watase
- Department of Surgery, University of Washington, Seattle, Washington, United States of America
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Comparison of video laryngoscopy versus direct laryngoscopy for intubation in emergency department patients with cardiac arrest: A multicentre study. Resuscitation 2018; 136:70-77. [PMID: 30385385 DOI: 10.1016/j.resuscitation.2018.10.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/04/2018] [Accepted: 10/08/2018] [Indexed: 01/18/2023]
Abstract
AIM To compare the tracheal intubation performance between video laryngoscopy (VL) and direct laryngoscopy (DL) in patients with cardiac arrest in the ED. METHODS This is an analysis of the data from a prospective, multicentre study of 15 EDs in Japan. We included consecutive adult patients with cardiac arrest who underwent intubation with VL or DL from 2012 through 2016. The primary outcome was first-attempt success. The secondary outcomes were glottic visualisation assessed with Cormack grade (1 vs. 2-4) and occurrence of oesophageal intubation. To examine the between-device difference in outcome risks, we analysed the whole data and 1:1 propensity score matched data. RESULTS Among 9694 patients who underwent intubation in the EDs, 3360 cardiac arrests (35%) were included in the analysis (90% were non-traumatic cardiac arrests). The first-attempt success rate was higher in the VL group compared to those in the DL (78% vs 70%; unadjusted OR 1.61 [95%CI 1.26-2.06] P < 0.001). This association remained significant after adjusting for six potential confounders and within-ED clustering (adjusted OR 1.33 [95%CI 1.03-1.73] P = 0.03). VL use was also associated with a better glottic visualisation (adjusted OR 3.84 [95%CI 2.81-5.26] P < 0.001) and lower rate of oesophageal intubation (adjusted OR 0.45 [95%CI 0.24-0.85] P = 0.01) compared to DL. These results were consistent in the propensity score matched analysis. CONCLUSIONS Based on large multicentre prospective data of ED patients with cardiac arrest, the use of VL was associated with a higher first-attempt success rate compared to DL, with a better glottic visualisation and lower oesophageal intubation rate.
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Associations of obesity with tracheal intubation success on first attempt and adverse events in the emergency department: An analysis of the multicenter prospective observational study in Japan. PLoS One 2018; 13:e0195938. [PMID: 29672600 PMCID: PMC5908180 DOI: 10.1371/journal.pone.0195938] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 04/03/2018] [Indexed: 11/20/2022] Open
Abstract
Obesity is deemed to increase the risk of difficult tracheal intubation. However, there is a dearth of research that examines the relationship of obesity with intubation success and adverse events in the emergency department (ED). We analyzed the data from a prospective, observational, multicenter study—the Japanese Emergency Airway Network (JEAN) 2 study from 2012 through 2016. We included all adults (aged ≥18 years) who underwent tracheal intubation in the ED. Patients were categorized into three groups according to their body mass index (BMI): lean (<25.0 kg/m²), overweight (25.0–29.9 kg/m²), and obesity (≥30.0 kg/m²). Outcomes of interest were intubation success on the first attempt and intubation-related adverse events. Of 6,889 patients who are eligible for the analysis, 5,370 patients (77%) were lean, 1,177 (17%) were overweight, and 342 (4%) were obese. Compared to the lean patients, the intubation success rates were significantly lower in the overweight and obese patients (70.9% in lean, 66.4% in overweight, and 59.3% in obese patients; P<0.001). In the multivariable analysis, compared to the lean patients, overweight (adjusted odds ratio [OR], 0.85; 95%CI, 0.74–0.98) and obese (adjusted OR, 0.62; 95%CI, 0.49–0.79) patients had a significantly lower success rate on the first attempt. Additionally, obesity was significantly associated with a higher risk of adverse events (adjusted OR, 1.62; 95%CI, 1.23–2.13). Based on the data from a multicenter prospectively study, obesity was associated with a lower success rate on the first intubation attempt and a higher risk of adverse event in the ED.
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Takahashi J, Goto T, Okamoto H, Hagiwara Y, Watase H, Shiga T, Hasegawa K. Association of fentanyl use in rapid sequence intubation with post-intubation hypotension. Am J Emerg Med 2018; 36:2044-2049. [PMID: 29653790 DOI: 10.1016/j.ajem.2018.03.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/11/2018] [Accepted: 03/13/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The anesthesia literature has reported that pre-intubation fentanyl use is associated with post-intubation hypotension which is a risk factor of poor post-emergency department (ED) prognosis. However, little is known about the relations between fentanyl use for intubation and post-intubation hypotension in the ED. We aimed to determine whether pretreatment with fentanyl was associated with a higher risk of post-intubation hypotension in the ED. METHODS We conducted a secondary analysis of data of ED airway management collected from a multicenter prospective study of 14 Japanese EDs from February 2012 through November 2016. We included all adult non-cardiac-arrest patients who underwent rapid sequence intubation for medical indication. Patients were divided into fentanyl and non-fentanyl groups. The primary outcome was post-intubation hypotension (systolic blood pressure ≤90mmHg) in the ED. RESULTS Of 1263 eligible patients, 466 (37%) patients underwent pretreatment with fentanyl. The fentanyl group had a higher risk of post-intubation hypotension (17% vs. 6%; unadjusted OR, 1.73; 95%CI, 1.01-2.97; P=0.048) compared to the non-fentanyl group. In the multivariable analysis adjusting for age, sex, weight, principal indication, sedatives, intubator's specialty, number of intubation attempts, and patient clustering within EDs, the fentanyl group had a higher risk of post-intubation hypotension (adjusted OR, 1.87; 95%CI, 1.05-3.34; P=0.03) compared to the non-fentanyl group. In the sensitivity analysis using propensity score matching, this association remained significant (OR, 3.17; 95%CI, 1.96-5.14; P<0.01). CONCLUSION In this prospective multicenter study of ED airway management, pretreatment with fentanyl in rapid sequence intubation was associated with higher risks of post-intubation hypotension.
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Affiliation(s)
- Jin Takahashi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba 279-0001, Japan.
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA
| | - Hiroshi Okamoto
- Center for Clinical Epidemiology, St. Luke's International University, 3-6 Tsukiji, Chuo, Tokyo 104-0045, Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan
| | - Hiroko Watase
- Department of Radiology, University of Washington, 850 Republican Street Seattle, WA 98006, USA
| | - Takashi Shiga
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, Chiba 279-0001, Japan; Department of Emergency Medicine, International University of Health and Welfare, 1-4-3 Mita, Minato, Tokyo 108-8329, Japan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
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Goto Y, Goto T, Hagiwara Y, Tsugawa Y, Watase H, Okamoto H, Hasegawa K. Techniques and outcomes of emergency airway management in Japan: An analysis of two multicentre prospective observational studies, 2010-2016. Resuscitation 2017; 114:14-20. [PMID: 28219617 DOI: 10.1016/j.resuscitation.2017.02.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Continuous surveillance of emergency airway management practice is imperative in improving quality of care and patient safety. We aimed to investigate the changes in the practice of emergency airway management and the related outcomes in the emergency departments (EDs) in Japan. METHODS We conducted an analysis of the data from two prospective, observational, multicentre registries of emergency airway management-the Japanese Emergency Airway Network (JEAN)-1 and -2 Registries from April 2010 through May 2016. RESULTS We recorded 10,927 ED intubations (capture rate, 96%); 10,875 paediatric and adult patients were eligible for our analysis. The rate of rapid sequence intubation (RSI) use as the initial intubation method significantly increased from 28% in 2010 to 53% in 2016 (Ptrend=0.03). Likewise, the rate of video laryngoscope (VL) use as the first intubation device increased significantly from 2% in 2010 to 40% in 2016 (Ptrend<0.001), with a significant decrease in the rate of direct laryngoscope use from 97% in 2010 to 58% in 2016 (Ptrend<0.001). Concurrent with these changes, the overall first-attempt success rate also increased from 68% in 2010 to 74% in 2016 (Ptrend=0.02). By contrast, the rate of adverse events did not change significantly over time (Ptrend=0.06). CONCLUSION By using data from two large, multicentre, prospective registries, we characterised the current emergency airway management practice, and identified their changes in Japan. The data demonstrated significant increases in the rate of RSI and VL use on the first attempt and the first-attempt success rate over the 6-year study period.
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Affiliation(s)
- Yukari Goto
- Department of Emergency Medicine, Nagoya Ekisaikai Hospital, 4-66 Shonen, Nakagawa, Nagoya, Aichi 454-8502, Japan.
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA
| | - Yusuke Hagiwara
- Department of Paediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Centre, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan
| | - Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue Boston, MA 02115, USA
| | - Hiroko Watase
- Department of Radiology, University of Washington, 850 Republican Street Seattle, WA 98006, USA
| | - Hiroshi Okamoto
- Centre for Clinical Epidemiology, Department of Emergency Medicine, St. Luke's International Hospital, 3-6 Tsukiji, Chuo, Tokyo 104-0045, Japan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
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