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Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes*

Parker, Margaret M. MD, MCCM; Nuthall, Gabrielle MB ChB, FRACP, FCICM; Brown, Calvin III MD; Biagas, Katherine MD; Napolitano, Natalie MPH, RRT-NPS, FAARC; Polikoff, Lee A. MD; Simon, Dennis MD; Miksa, Michael MD, PhD, FAAP; Gradidge, Eleanor MD, FAAP; Lee, Jan Hau MBBS, MRCPCH, MCI; Krishna, Ashwin S. MD; Tellez, David MD, FCCM; Bird, Geoffrey L. MD, MSIS; Rehder, Kyle J. MD; Turner, David A. MD; Adu-Darko, Michelle MD, FAAP; Nett, Sholeen T. MD, PhD; Derbyshire, Ashley T. MSN, RN, PNP-AC; Meyer, Keith MD; Giuliano, John Jr MD; Owen, Erin B. MD; Sullivan, Janice E. MD; Tarquinio, Keiko MD, FAAP; Kamat, Pradip MD; Sanders, Ronald C. Jr MD, MS; Pinto, Matthew MD; Bysani, G. Kris MD, FAAP, FCCM; Emeriaud, Guillaume MD, PhD; Nagai, Yuki MD; McCarthy, Melissa A. RRT; Walson, Karen H. MD; Vanderford, Paula MD, FAAP; Lee, Anthony MD, FAAP; Bain, Jesse DO; Skippen, Peter MD; Breuer, Ryan MD; Tallent, Sarah MSN, RN, CPNP-AC; Nadkarni, Vinay MD, MS; Nishisaki, Akira MD, MSCE; for the National Emergency Airway Registry for Children (NEAR4KIDS) Investigators and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network

Pediatric Critical Care Medicine: April 2017 - Volume 18 - Issue 4 - p 310–318
doi: 10.1097/PCC.0000000000001074
Feature Articles

Objective: Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality.

Study Design: Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%.

Setting: PICUs participating in NEAR4KIDS.

Patients: All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed.

Measurements and Main Results: Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58–229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1–7 yr and 18% for 8–17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4–21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24–2.60; p = 0.002), after adjusted for patient confounders.

Conclusions: Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.

1Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children’s Hospital, Stony Brook, NY.

2Department of Pediatrics, Pediatric Intensive Care Unit, Starship Children’s Hospital, Auckland, New Zealand.

3Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA.

4Department of Pediatrics, Columbia University/New York Presbyterian Hospital, New York, NY.

5Department of Respiratory Care, The Children’s Hospital of Philadelphia, Philadelphia, PA.

6Division of Pediatric Critical Care Medicine, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Providence, RI.

7Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA.

8Department of Pediatric Critical Care Medicine, The Children’s Hospital at Montefiore, Bronx, NY.

9Department of Pediatrics, Phoenix Children’s Hospital, Phoenix, AZ.

10Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, Singapore.

11Division of Pediatric Critical Care, Department of Pediatrics, Kentucky Children’s Hospital, University of Kentucky School of Medicine, Lexington, KY.

12Department of Child Health University of Arizona College of Medicine, Department of Critical Care Phoenix Children’s Hospital, Phoenix, AZ.

13Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA.

14Division of Critical Care, Department of Pediatrics, Duke Children’s Hospital, Durham, NC.

15Pediatric Critical Care Medicine, The University of Virginia Children’s Hospital, Charlottesville, VA.

16Division of Pediatric Critical Care, Children’s Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH.

17Pediatric Critical Care Medicine, Penn State Hershey Children’s Hospital, Hershey, PA.

18Pediatric Critical Care Medicine, Nicklaus Children’s Hospital, Miami Children’s Health System, Miami, FL.

19Critical Care Medicine, Department of Pediatrics, Yale Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT.

20Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Louisville, KY.

21Pediatric Critical Care Medicine, Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.

22Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas College of Medicine, Little Rock, AR.

23Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children’s Hospital Westchester Medical Center, Valhalla, NY.

24Pediatric Critical Care Medicine, Medical City Children’s Hospital, Dallas, TX.

25Department of Pediatrics, Sainte-Justine University Hospital Center, Montreal, QC, Canada.

26Department of Emergency Medicine, Tokyo Metropolitan Children’s Medical Centre, Tokyo, Japan.

27Department of Critical Care Medicine, Children’s Hospital of Pittsburgh at University of Pittsburgh Medical Center, Pittsburgh, PA.

28Division of Pediatric Critical Care Medicine, Children’s Healthcare of Atlanta at Scottish Rite, Atlanta, GA.

29Division of Pediatric Critical Care Medicine, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR.

30Division of Critical Care, Nationwide Children’s Hospital, Columbus, OH.

31Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Richmond at VCU, Richmond, VA.

32Department of Pediatrics, BC Children’s Hospital, University of British Columbia, Vancouver, BC, Canada.

33Division of Critical Care, Department of Pediatrics, Women & Children’s Hospital of Buffalo, Buffalo, NY.

34Division of Pediatric Cardiac Intensive Care, Department of Pediatric Critical Care Medicine, Duke Children’s Hospital & Health Center, Durham, NC.

*See also p. 381.

The PALISI Executive Committee are as follows: Ann Thompson, MD; Ira Cheifetz, MD; Martha Curley, PhD; Jacques Lacroix, MD; Dan Levin, MD; Neal Thomas, MD; Adrienne Randolph, MD; Marissa Tucci, MD; Douglas Willson, MD.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Dr. Nuthall’s institution received funding from the A+ Trust Grant (to contribute to research nurses salary who helped collect data). Dr. Brown III disclosed receiving support from the Airway Management Education Center, LLC (partner). Ms. Napolitano’s institution received funding from AHRQ (R03HS021583 and R18HS022464), Draeger Medical, Aerogen, and Nihon Kohden, and she disclosed receiving support in the form of consulting relationships with Actuated Medical Incorporated, Allergy and Asthma Network, being on the board of directors for American Association for Respiratory Care and Asthma and Allergy Network, and a program grant to CHOP from CVS Health. Dr. Gradidge received funding from Pfizer. Dr. Sullivan received support for article research from the National Institutes of Health. Dr. Emeriaud’s institution received funding from GE's research program (supported by a clinical research scholarship from the Fonds de la Recherche du Québec - Santé). Dr. Nagai disclosed work for hire. Dr. Nadkarni was supported by AHRQ R03HS021583 and AHRQ R18HS022464, and holds the Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia. Dr. Nishisaki received support for article research from the Agency for Healthcare Research and Quality (AHRQ); his institution received funding from AHRQ R03HS021583 and R18HS022464; and he disclosed receiving support from holding the Endowed Chair, Critical Care Medicine, the Children's Hospital of Philadelphia. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: nishisaki@email.chop.edu

©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies