Ilana Harwayne-Gidansky

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.

Improving multidisciplinary involvement at the critical care congress through social media

Learning Objectives: The Society of Critical Care Medicine promotes a collaborative multidisciplinary practice, with a team consisting of professionals in different fields. Participation in social media activities, such as live-tweeting a meeting provides a unique opportunity for members of all professions to participate, and may allow for inclusion of a more diverse group in discussions. We assessed participation using social media metrics by physicians and non-physicians in conversations at the annual Critical Care Congress (CCC). Methods: Symplur Analytics were used to compare the characteristics of those who tweeted using the 2015 and 2016 CCC hashtag (#CCC44 and #CCC45, respectively). Characteristics of the top 50 participants during the conference were compared. Allied health professionals (AHP) were defined as non-physician healthcare providers. Results: There was an increase in tweets and participants from 2015 (4,374 tweets, 625 participants) to 2016 (14,358 tweets, 1,693 participants). In 2015, 27 of the top 50 tweeters were physicians, 7 were AHP (2 nurses, 2 advanced practitioners, and 1 pharmacist), 10 were organizations, and 6 were other non-healthcare individuals. In 2016, 22 of the top 50 tweeters were physicians, 17 were AHP (2 nurses, 5 advanced practitioners, 5 pharmacists, 2 dietitians, and 3 other providers), 8 were organizations, and 3 were other non-healthcare individuals. There were significantly more AHP participating in social media during 2016 CCC compared to 2015 (34% vs 14% of the top 50 accounts; p=0.047). The number of followers of AHP accounts were significantly fewer than the number of followers of the physician accounts (800 ± 626 followers vs 1,608 ± 2,282 followers; p=0.02), but there was no significant difference in number of tweets (7,403 ± 8,993 vs 16,764 ± 36,230 tweets; p=0.1) or duration of time on Twitter (4.8 ± 2.3 vs 5.1 ± 2.1 yrs; p=0.6). Conclusions: Social media is another way to engage all heath care professionals in academic conversations that occur during CCC. More effort should be made to increase inclusion in this important venue for multidisciplinary conversation.

1116: END-TIDAL CARBON DIOXIDE MONITORING FOR TRACHEAL INTUBATION

Learning Objectives: Quantitative end-tidal carbon dioxide (qEtCO2) measurement with capnography device (CD) is becoming more available in pediatric ICUs and EDs. Yet CD utilization for confirmation of tracheal intubation (TI) is not known across variable pediatric ICUs and EDs. Clinical significance of CD use in detection of esophageal intubation, and prevention of acute desaturation (SpO2<80%) during TI are also unknown. We hypothesize that CD use to confirm TI success has become more common in both ICUs and EDs, and associated with lower occurrence of esophageal intubation with delayed recognition (DEI) and desaturation. Methods: Prospective multicenter cohort of a pediatric airway quality improvement database (NEAR4KIDS) between 7/2010 and 12/2015 was analyzed with inclusion criteria: age<18yr with initial TI. We evaluated the trend of CD use over time, and the association between CD use and the occurrence DEI/desaturation, while adjusting for patient, provider, location and clustering by site. Chi2 test for univariate analyses, multivariable logistic regression with GEE model, p<0.05 as significant. Results: Among 11,239 TIs (ICU:10,698, ED:541) from 34 sites, CDs were used in 45% in ICUs and 66% in EDs (p<0.001). CD use was significantly increased overtime in both locations (year 2015, ICU:52%, ED:73%, p<0.01 for trend at both locations). There was significant site variability in CD use (median 50%, IQR 25–85%, p<0.001). The use of a CD was less common in TI for respiratory failure (p<0.001) and by resident providers (p<0.001). DEI was reported in 0.44%; the occurrence was not different in TIs with/without a CD (with capnography 0.38% vs. without 0.48%, OR 0.78, p=0.34). Desaturations <80% were seen in 17% (with CD 16% vs. without CD 19%, OR 0.98, 95% CI: 0.96–0.99, p=0.003). Conclusions: There is large practice variation in CD use in pediatric ICUs and EDs. CD use was also significantly associated with fewer occurrences of desaturations, but not with DEI.

1142Critically Ill Children Hospitalized with an Acute Respiratory Viral Infection: Characterizing ICU severity

Background. Acute respiratory viral infections (ARVI) are a common public health problem with a significant global health care burden. There is no comprehensive data on which viral pathogen or pathogens are associated with the highest severity in children with ARVI requiring intensive care. We characterized the severity of critical illness secondary to ARVI in a Pediatric Intensive Care Unit (PICU). We hypothesized that no single virus would consistently correlate with a greater severity of illness. Methods. We performed a retrospective chart review of children ≤18 years of age with a respiratory viral infection and a positive PCR test (Respiratory Viral Panel, Biofire) requiring PICU admission in a 23-bed New York City PICU between 2010-2013. We described and analyzed the clinical characteristics of infected children. The institutional review board of Weill Cornell Medical College approved conduct of this study with a waiver of informed consent. Results. Our PICU admitted 2957 patients during the study period, of which 245 (8%) tested positive for a viral pathogen. The average age was 3.08 years (0.04-19.45), compared to an average age of 3.48 years for the general PICU population. Most patients with a positive viral assay also had an underlying medical condition (78%). 103 patients (42%) with a respiratory virus were intubated and 27 patients (18.6%) had a tracheostomy, compared to 221 (7.5%) and 81 patients (2.7%) respectively in the general PICU population during the same period. Rhinovirus was the most common pathogen, comprising 55% of our cohort. RSV comprised 13%. Regarding severity, adenovirus (p = 0.06) and parainfluenza (p = 0.01) were associated with a longer length of stay in both the PICU and hospital. Additionally, 67% of children with adenovirus required mechanical ventilation vs only 29% of children with RSV, though these results did not achieve statistical significance. Conclusion. Our data suggests that while no single virus was responsible for an overall greater severity of illness, parainfluenza and adenovirus trended towards this; further study is needed. Overall, respiratory viruses have a considerable pediatric healthcare and critical care burden. Disclosures. All authors: No reported disclosures.