Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department
Background The risk factors for peri‐intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED). Methods This was a retrospective c...
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| Published in: | Academic emergency medicine Vol. 27; no. 12; pp. 1241 - 1248 |
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| Main Authors: | , , , , , , , , , , , , |
| Format: | Journal Article |
| Language: | English |
| Published: |
United States
Wiley Subscription Services, Inc
01-12-2020
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| Subjects: | |
| Online Access: | Get full text |
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| Summary: | Background
The risk factors for peri‐intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED).
Methods
This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high‐risk criteria for peri‐intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post–return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri‐intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in‐hospital mortality. We compared outcomes between patients meeting one or more versus no high‐risk criteria.
Results
Peri‐intubation cardiac arrest occurred in 5.6% of patients who met at least one high‐risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in‐hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first‐pass intubation success (47.2% vs. 66.1%, −18.9% difference, 95% CI = −35.5 to −1.5, p = 0.038), respectively.
Conclusions
We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post‐ROSC are at higher risk for peri‐intubation cardiac arrest and in‐hospital mortality. Further multicenter investigation is needed to validate our findings. |
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| Bibliography: | The authors have no relevant financial information or potential conflicts to disclose. Author contributions: PD, EH, AJL, BK, and GG were responsible for study concept and design; PD and MF were responsible for acquisition of the data; PD and YZ were responsible for analysis and interpretation of the data; PD was responsible for drafting the first version of the manuscript; AJL, EH, GG, MF, MC, BK, ES, MZ, and AM were responsible for critical revision of the manuscript for important intellectual content; and all authors approved the final version. Presented at the Pediatric Academic Societies Meeting virtually through the Academic Pediatric Association’s mobile application, 2020. ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23 |
| ISSN: | 1069-6563 1553-2712 |
| DOI: | 10.1111/acem.14128 |