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A Study of Practice Behavior for Endotracheal Intubation Site for Children With Congenital Heart Disease Undergoing Surgery: Impact of Endotracheal Intubation Site on Perioperative Outcomes—An Analysis of the Society of Thoracic Surgeons Congenital Cardiac Anesthesia Society Database

Greene, Nathaniel H. MD, MHS*; Jooste, Edmund H. MB, ChB; Thibault, Dylan P. MS; Wallace, Amelia S. MS§; Wang, Alice MD; Vener, David F. MD; Matsouaka, Roland A. PhD#; Jacobs, Marshall L. MD**; Jacobs, Jeffrey P. MD††; Hill, Kevin D. MD‡‡; Ames, Warwick A. MBBS, FRCA

doi: 10.1213/ANE.0000000000003594
Pediatric Anesthesiology: Original Clinical Research Report

BACKGROUND: In adults undergoing cardiopulmonary bypass surgery, oral intubation is typically preferred over nasal intubation due to reduced risk of sinusitis and infection. In children, nasal intubation is more common and sometimes preferred due to perceived benefits of less postoperative sedation and a lower risk for accidental extubation. This study sought to describe the practice of nasal intubation in the pediatric population undergoing cardiopulmonary bypass surgery and assess the risks/benefits of a nasal route against an oral one.

METHODS: Patients <18 years of age in the Society of Thoracic Surgeons Congenital Heart Surgery Database between January 2010 and December 2015 were included. Patients with a preoperative endotracheal tube, tracheostomy, or known airway anomalies were excluded. Multivariable modeling was used to assess the association between route of tracheal intubation and a composite measure of infection risk (wound infection, mediastinitis, septicemia, pneumonia, and endocarditis). Covariates were included to adjust for important patient characteristics (eg, weight, age, comorbidities), case complexity, and center effects. Secondary outcomes included length of intubation, hospital length of stay, and airway complications including accidental extubations. We also performed a subanalysis in children <12 months of age in high-volume centers (>100 cases/y) examining how infection risk may change with age at the time of surgery.

RESULTS: Nasal intubation was used in 41% of operations in neonates, 38% in infants, 15% in school-aged children, and 2% in adolescents. Nasal intubation appeared protective for accidental extubation only in neonates (P = .02). Multivariable analysis in infants and neonates showed that the nasal route of intubation was not associated with the infection composite (relative risk [RR], 0.84; 95% CI, 0.59–1.18) or a shorter length of stay (RR, 0.992; 95% CI, 0.947–1.039), but was associated with a shorter intubation length (RR, 0.929; 95% CI, 0.869–0.992). Restricting to high-volume centers showed a significant interaction between age and intubation route with a risk change for infection occurring between approximately 6–12 months of age (P = .003).

CONCLUSIONS: While older children undergoing nasal intubation trend similar to the adult population with an increased risk of infection, nasal intubation in neonates and infants does not appear to carry a similar risk. Nasal intubation in neonates and infants may also be associated with a shorter intubation length but not a shorter length of stay. Prospective studies are required to better understand these complex associations.

From the *Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina

Department of Anesthesiology and Pediatrics, Duke University School of Medicine, Durham, North Carolina

Biostatistician III

§Biostatistician II

Duke Clinical Research Institute, Durham, North Carolina

Pediatric Cardiovascular Anesthesiology, Department of Anesthesiology, Baylor College of Medicine/Texas Children’s Hospital, Houston, Texas

#Biostatistics and Bioinformatics & Duke Clinical Research Institute, Duke University, Durham, North Carolina

**Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland

††Division of Cardiac Surgery, Department of Surgery, Johns Hopkins All Children’s Heart Institute, St Petersburg, Florida

‡‡Department of Pediatrics, Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina.

Published ahead of print 21 May 2018.

Accepted for publication May 21, 2018.

Funding: This study was funded jointly by the Society of Thoracic Surgeons and the Congenital Cardiac Anesthesia Society.

The authors declare no conflicts of interest.

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.

Reprints will not be available from the authors.

Address correspondence to Nathaniel H. Greene, MD, MHS, Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710. Address e-mail to

Copyright © 2018 International Anesthesia Research Society
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