Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit
Department of Anesthesiology and Critical Care Medicine, Center for Simulation, Advanced Education and Innovation, The Children's Hospital of Philadelphia, Philadelphia, PA, USA. Pediatric Critical Care Medicine
(Impact Factor: 2.34).
11/2010; 13(1):e5-10. DOI: 10.1097/PCC.0b013e3181fe472d
To characterize tracheal intubation process of care and safety outcomes in a large tertiary pediatric intensive care unit using a pediatric adaptation of the National Emergency Airway Registry. Variances in process of care and safety outcome of intubation in the pediatric intensive care unit have not been described. We hypothesize that tracheal intubation is a common but high-risk procedure and that the novel pediatric adaptation of the National Emergency Airway Registry is a feasible tool to capture variances in process of care and outcomes.
Prospective descriptive study.
A single 45-bed tertiary noncardiac pediatric intensive care unit in a large university-affiliated children's hospital.
Critically ill children who required intubation in the pediatric intensive care unit.
Airway management data were prospectively collected for all initial airway management from July 2007 through September 2008 using the National Emergency Airway Registry tool tailored for pediatric application with explicit operational definitions.
One hundred ninety-seven initial intubation encounters were reported (averaging one every 2.3 days). The first course intubation method was oral intubation in 181 (91.9%) and nasal in 16 (9.1%). Unwanted tracheal intubation-associated events were frequently reported (n = 38 [19.3%]), but severe tracheal intubation-associated events were rare (n = 6 [3.0%]). Esophageal intubation with immediate recognition was the most common tracheal intubation-associated event (n = 22). Desaturation <80% was reported in 51 of 183 (27.7%) and more than two intubation attempts in 30 of 196 (15.3%), both associated with occurrence of a tracheal intubation-associated event (p < .001, p = .001, respectively). Interestingly, patient age, history of difficult airway, and first attempt by resident were not associated with tracheal intubation-associated events.
Unwanted tracheal intubation-associated events occurred frequently, but severe tracheal intubation-associated events were rare. Our novel registry can be used to describe the pediatric intensive care unit tracheal intubation procedural process of care and safety outcomes.
Figures in this publication
Available from: Kohei Hasegawa
- "Cardiac arrest includes asystole, bradycardia or dysrhythmia with non-measurable blood pressure and cardiopulmonary resuscitation during or after intubation. Oesophageal intubation was defined as misplacement of the tracheal tube in the upper oesophagus or hypopharynx with a lapse of time and clinical deterioration, such as hypoxemia, before the removal of the misplaced tube [16-18]. Regurgitation was defined as gastric contents that required suction removal during laryngoscopy in a previously clear airway. "
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Although the number of elderly increases disproportionately throughout the industrialised nations and intubation-related cardiovascular compromise is associated with hospital mortality, no emergency medicine literature has reported the direction and magnitude of effect of advanced age on post-intubation hypotension. We seek to determine whether advanced age is associated with an increased rate of hypotension at airway management in emergency departments (EDs).
We conducted an analysis of a multi-centre prospective observational study of 13 Japanese EDs from April 2010 to March 2012. Inclusion criteria were all adult non-cardiac-arrest patients who underwent emergency intubation. We excluded patients in whom airway management was performed for shock or status asthmaticus as the principal indication. Patients were divided into two groups defined a priori: age ≥ 65 years old (elderly group) and age < 65 years old (younger group). The primary outcome measure was post-intubation hypotension in the ED.
During the 24-month period, 4,043 subjects required emergency airway management at 13 EDs. Among these, the database recorded 3,872 intubations (capture rate 96%). Of 1,903 eligible patients, 975 patients were age ≥ 65 years (51%) and 928 patients were age < 65 years (49%). The elderly group had a significantly higher rate of post-intubation hypotension compared with the younger group [3% vs. 1%; unadjusted OR 2.7 (95% CI, 1.3–5.6); P = 0.005]. In a model controlling for potential confounders (sex, principal indication, method, medication used to intubate, multiple intubation attempts), advanced age had an adjusted OR for post-intubation hypotension of 2.6 (95% CI, 1.3–5.6; P = 0.01).
In this large multi-centre study of ED patients who underwent emergent airway management, we found that elderly patients have a significantly higher risk of post-intubation hypotension. These data provide implications for the education and practice of ED airway management that may lead to better clinical outcomes and improved patient safety.
International Journal of Emergency Medicine 04/2013; 6(1):12. DOI:10.1186/1865-1380-6-12
Available from: Kohei Hasegawa
- "" Adverse events " were a priori defined as airway management-associated events with two categories: major and minor adverse events. A major adverse event was defined as a cardiac arrest, hypotension, hypoxemia, dysrhythmia, regurgitation, or esophageal intubation with delayed recognition . Cardiac arrest included asystole, bradycardia, or dysrhythmia with nonmeasurable blood pressure and cardiopulmonary resuscitation required during or after intubation. "
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There is little information on geriatric emergency airway management. We sought to describe intubation practices and outcomes for emergency department (ED) geriatric and younger patients in Japan.
We formed the Japanese Emergency Airway Network, a consortium of 11 medical centers, and prospectively collected data on ED intubations between 2010 and 2011. All patients 18 years or older who underwent emergent airway management were included in our study. Patients were divided to into 2 groups: 18 to 64-year olds and 65 years or older. We present descriptive data as proportions with 95% confidence intervals (CI).
The database recorded 3277 patients (capture rate 96%), and 3178 met the inclusion criteria. Of 3178 patients, 1844 (58%) were 65 years or older, 1334 (42%) were 18 to 64 years old, 809 (25%) were 80 years or older, and 407 (50%) of them were in the state of cardiac arrest. The geriatric group, compared to the younger group, had a higher success rate on the initial attempt (71% vs 64%; difference 7%; 95% CI 4%-10%;) and in 2 attempts (90% vs 88%; difference 3%; 95% CI 1%-5%) or less. There was no significant difference in the adverse event rates by age group (difference 0%; 95% CI -2% to 3%).
In our multicenter study involving a large geriatric population, we found that geriatric patients were intubated with a higher success rate, compared to younger patients. These data provide implications for the geriatric ED airway practice that may lead to better patient-centered emergency care.
The American journal of emergency medicine 10/2012; 31(1). DOI:10.1016/j.ajem.2012.07.008 · 1.27 Impact Factor
Pediatric Critical Care Medicine 01/2012; 13(1):108-9. DOI:10.1097/PCC.0b013e318202f5dc · 2.34 Impact Factor
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