Eleanor Gradidge

Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes

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.

Trend and Outcomes of Video Laryngoscope Use Across Picus.

Objective: Video (indirect) laryngoscopy is used as a primary tracheal intubation device for difficult airways in emergency departments and in adult ICUs. The use and outcomes of video laryngoscopy compared with direct laryngoscopy has not been quantified in PICUs or cardiac ICUs. Design: Retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from July 2010 to June 2015. Setting: Thirty-six PICUs/cardiac ICUs across the United States, Canada, Japan, New Zealand, and Singapore. Patients: Any patient admitted to a PICU or a pediatric cardiac ICU and undergoing tracheal intubation. Interventions: Use of direct laryngoscopy versus video laryngoscopy for tracheal intubation. Measurements and Main Results: There were 8,875 tracheal intubations reported in the National Emergency Airway Registry for Children database, including 7,947 (89.5%) tracheal intubations performed using direct laryngoscopy and 928 (10.5%) tracheal intubations performed using video laryngoscopy. Wide variability in video laryngoscopy use exists across PICUs (median, 2.6%; range, 0–55%). Video laryngoscopy was more often used in older children (p < 0.001), in children with history of a difficult airway (p = 0.01), in children intubated for ventilatory failure (p < 0.001), and to facilitate the completion of an elective procedure (p = 0.048). After adjusting for patient-level covariates, a secular trend, and site-level variance, the use of video laryngoscopy significantly increased over a 5-year period compared with fiscal year 2011 (odds ratio, 6.7; 95% CI, 1.7–26.8 for fiscal year 2014 and odds ratio, 11.2; 95% CI, 3.2–38.9 for fiscal year 2015). The use of video laryngoscopy was independently associated with a lower occurrence of tracheal intubation adverse events (adjusted odds ratio, 0.57; 95% CI, 0.42–0.77; p < 0.001) but not with a lower occurrence of severe tracheal intubation adverse events (adjusted odds ratio, 0.86; 95% CI, 0.56–1.32; p = 0.49) or fewer multiple attempts at endotracheal intubation (adjusted odds ratio, 0.93; 95% CI, 0.71–1.22; p = 0.59). Conclusions: Using National Emergency Airway Registry for Children data, we described patient-centered adverse outcomes associated with video laryngoscopy compared with direct laryngoscopy for tracheal intubation in the largest reported international cohort of children to date. Data from this study may be used to design sufficiently powered prospective studies comparing patient-centered outcomes for video laryngoscopy versus direct laryngoscopy during endotracheal intubation.

Clinical Impact of External Laryngeal Manipulation During Laryngoscopy on Tracheal Intubation Success in Critically Ill Children

Objectives: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. Design: A retrospective observational study using a multicenter emergency airway quality improvement registry. Setting: Thirty-five PICUs within general and children’s hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). Patients: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. Measurements and Main Results: Propensity score–matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62–0.75; p < 0.001). In propensity score–matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90–0.95; p < 0.001). Conclusions: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.

Effect of Location on Tracheal Intubation Safety in Cardiac Disease—Are Cardiac ICUs Safer?

Objectives: Evaluate differences in tracheal intubation–associated events and process variances (i.e., multiple intubation attempts and oxygen desaturation) between pediatric cardiac ICUs and noncardiac PICUs in children with underlying cardiac disease. Design: Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). Setting: Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. Patients: Children with medical or surgical cardiac disease who underwent intubation in an ICU. Interventions: None. Measurements and Main Results: Our primary outcome was the rate of any adverse tracheal intubation–associated event. Secondary outcomes were severe tracheal intubation–associated events, multiple tracheal intubation attempt rates, and oxygen desaturation. There were 1,502 tracheal intubations in children with underlying cardiac disease (751 in cardiac ICUs, 751 in noncardiac ICUs) reported. Cardiac ICUs and noncardiac ICUs had similar proportions of patients with surgical cardiac disease. Patients undergoing intubation in cardiac ICUs were younger (median age, 1 mo [interquartile range, 0–6 mo]) compared with noncardiac ICUs (median 3 mo [interquartile range, 1–11 mo]; p < 0.001). Tracheal intubation–associated event rates were not different between cardiac ICUs and noncardiac ICUs (16% vs 19%; adjusted odds ratio, 0.74; 95% CI, 0.54–1.02; p = 0.069). However, in a sensitivity analysis comparing cardiac ICUs with mixed ICUs (i.e., ICUs caring for children with either general pediatric or cardiac diseases), cardiac ICUs had decreased odds of adverse events (adjusted odds ratio, 0.71; 95% CI, 0.52–0.97; p = 0.033). Rates of severe tracheal intubation–associated events and multiple attempts were similar. Desaturations occurred more often during intubation in cardiac ICUs (adjusted odds ratio, 1.61; 95% CI, 1.04–1.15; p = 0.002). Conclusions: In children with underlying cardiac disease, rates of adverse tracheal intubation–associated events were not lower in cardiac ICUs as compared to noncardiac ICUs, even after adjusting for differences in patient characteristics and care models.

Acute Onset of Anemia After IV Immunoglobulin

A previously healthy 6-year-old boy was diagnosed to have bacterial meningitis and was treated for 6 days with intravenous (IV) ceftriaxone. His spinal fluid culture was negative. He developed difficulty in walking and vision loss and was diagnosed to have optic neuritis by the ophthalmologist. Consults by a neurologist followed by repeat spinal tap were consistent with a demyelinating process. Magnetic resonance imaging revealed multifocal areas of subcortical patchy T2/FLAIR signal hyperintensity with associated enhancement of the optic nerves. An electroencephalogram showed generalized slowing, indicative of diffuse encephalopathy. He was diagnosed to have acute disseminated encephalomyelitis (ADEM) and started on high-dose methylprednisolone burst with taper and IV immunoglobulin (IV IgG) 2 g/kg over 2 days. Within 48 hours after the infusion, his urine became very dark, and he appeared pale but not jaundiced. He continued to be active, with no evidence of impending failure. He had developed a grade 2/6 ejection systolic murmur best heard in the left second parasternal space. The liver was palpable 2 cm below the costal margin but nontender. The spleen was not palpable. He did not have joint swelling, skin rash, or edema. As regards to the laboratory investigations, hemoglobin (Hb) was noted to have decreased from 11.9 g/dl at admission 2 days earlier to 7.9 g/dl. Reticulocyte count was 2.6%, and mean corpuscular volume, mean corpuscular hemoglobin concentraction and red blood cell distribution width were normal. Peripheral smear showed normocytic, normochromic anemia with occasional spherocytes and polychromasia, indicating the possibility of hemolysis with an active marrow. Urinalysis was negative for red blood cells (RBCs) and blood. A direct Coombs was weakly reactive. The antibody was eluted from the RBCs and identified as passive anti-IgG anti-A and anti-B. The patient’s blood group was AB, and the indirect Coombs was negative. The specific batch of IV IgG was checked and revealed high anti-A and anti-B titers.