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Hemodynamic Impact of Oxygen Desaturation During Tracheal Intubation Among Critically Ill Children With Cyanotic and Noncyanotic Heart Disease*

Mokhateb-Rafii, Tanya, DO1; Bakar, Adnan, MD1,2; Gangadharan, Sandeep, MD1; Gradidge, Eleanor A., MD3; Tellez, David, MD4; Ruppe, Michael, MD5; Tallent, Sarah, RN, MSN, CPNP-AC6; Bird, Geoffrey, MD, MSIS7; Lavin, Natasha, BS, RRT-NPS, CPFT8; Lee, Anthony, MD9; Napolitano, Natalie, MPH, RRT-NPS, FAARC8; Nadkarni, Vinay, MD10; Shults, Justine, PhD11; Nishisaki, Akira, MD, MSCE10 for the National Emergency Airway Registry for Children (NEAR4KIDS) and Pediatric Acute Lung Injury and Sepsis Investigators (PALISI)

Pediatric Critical Care Medicine: January 2019 - Volume 20 - Issue 1 - p 19–26
doi: 10.1097/PCC.0000000000001766
Cardiac Intensive Care
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Objectives: To determine a level of oxygen desaturation from baseline that is associated with increased risk of tracheal intubation associated events in children with cyanotic and noncyanotic heart disease.

Design: Retrospective analysis of prospectively collected data from the National Emergency Airway Registry for Children, an international multicenter quality improvement collaborative for airway management in critically ill children.

Setting: Thirty-eight PICUs from July 2012 to December 2016.

Patients: Children with cyanotic and noncyanotic heart disease who underwent tracheal intubation in a pediatric or cardiac ICU.

Interventions: None.

Measurements and Main Results: Our exposure of interest was oxygen desaturation measured by a fall in pulse oximetry from baseline after preoxygenation. Primary outcome was the occurrence of hemodynamic tracheal intubation associated events defined as cardiac arrest, hypotension or dysrhythmia. One-thousand nine-hundred ten children (cyanotic, 999; noncyanotic, 911) were included. Patients with cyanotic heart disease who underwent tracheal intubations were younger (p < 0.001) with higher Pediatric Index of Mortality 2 scores (p < 0.001), more likely to have a cardiac surgical diagnosis (p < 0.001), and less likely to have hemodynamic instability (p = 0.009) or neurologic failure as an indication (p = 0.008). Oxygen desaturation was observed more often in children with cyanotic versus noncyanotic heart disease (desaturation of 15% to < 30%: 23% vs 16%, desaturation ≥ 30%: 23% vs 17%; p < 0.001), with no significant difference in occurrence of hemodynamic tracheal intubation associated events (7.5% vs 6.9%; p = 0.618). After adjusting for confounders, oxygen desaturation by 30% or more is associated with increased odds for adverse hemodynamic events (odds ratio, 4.03; 95% CI, 2.12–7.67) for children with cyanotic heart disease and (odds ratio, 3.80; 95% CI, 1.96–7.37) for children with noncyanotic heart disease.

Conclusions: Oxygen desaturation was more commonly observed during tracheal intubation in children with cyanotic versus noncyanotic heart disease. However, hemodynamic tracheal intubation associated event rates were similar. In both groups, oxygen desaturation greater than or equal to 30% was significantly associated with increased occurrence of hemodynamic tracheal intubation associated events.

1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, NY.

2Division of Pediatric Cardiology, Department of Pediatrics, Steven and Alexandra Cohen Children’s Medical Center, New Hyde Park, NY.

3Department of Pediatrics, Ochsner Hospital for Children, New Orleans, LA.

4Department of Critical Care, Phoenix Children’s Hospital, Phoenix, AZ.

5Division of Critical Care Medicine, Department of Pediatrics, Norton Children’s Hospital, University of Louisville School of Medicine, Louisville, KY.

6Division of Pediatric and Congenital Heart Center, Department of Pediatric Critical Care Medicine, Duke University Hospital, Durham, NC.

7Division of Cardiac Critical Care, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA.

8Department of Respiratory Therapy, Children’s Hospital of Philadelphia, Philadelphia, PA.

9Division of Pediatric Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH.

10Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA.

11Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

*See also p. 82.

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).

Supported, in part, by Agency for Healthcare Research and Quality (AHRQ) grants: AHRQ R03HS021583, AHRQ R18 HS022464, AHRQ R18HS024511; and the Endowed Chair, Critical Care Medicine, The Children’s Hospital of Philadelphia (to Dr. Nadkarni).

Dr. Napolitano’s institution received has research relationships with Nihon Kodhen, Aerogen, Draeger, Smith Medical, VERO-Biotech, Philips Respironics, and Actuated Medical. Drs. Napolitano’s, Shults’, and Nishisaki’s institutions received funding from Agency for Healthcare Research and Quality (AHRQ) R03HS021583, AHRQ R18 HS022464 and AHRQ R18HS024511. 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

©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies