Relationship between Adverse Tracheal Intubation Associated Events and Pediatric ICU Outcomes

• Authors: Margaret M. Parker, Stony Brook Children's Hospital; Gabrielle Nuthall, Starship Children's Health; Calvin Brown, Brigham and Women's Hospital; Katherine Biagas, Columbia University in the City of New York; Natalie Napolitano, The Children's Hospital of Philadelphia; Lee A. Polikoff, Brown University; Dennis Simon, University of Pittsburgh Medical Center; Michael Miksa, The Childen's Hospital at Montefiore; Eleanor Gradidge, Phoenix Children's Hospital; Jan Hau Lee, KK Women's And Children's Hospital; Ashwin S. Krishna, University of Kentucky Children's Hospital; David Tellez, University of Arizona; Geoffrey L. Bird, The Children's Hospital of Philadelphia; Kyle J. Rehder, Duke Children's Hospital; David A. Turner, Duke Children's Hospital; Michelle Adu-Darko, University of Virginia; Sholeen Nett, Children's Hospital at Dartmouth; Ashley T. Derbyshire, Penn State Hershey Children's Hospital; Keith Meyer, Nicklaus Children's Hospital; John Giuliano, Yale University; Erin Owen, University of Louisville; Janice E. Sullivan, University of Louisville; Keiko M. Tarquinio, Emory University; Pradip Kamat, Emory University; Ron C. Sanders, University of Arkansas at Little Rock; Matthew Pinto, Westchester Medical Center; G. Kriss Bysani, Medical City Children's Hospital; Guillaume Emeriaud, Sainte-Justine University Hospital Center; Yuki Nagai, Tokyo Metropolitan Children's Medical Center; Melissa A. McCarthy, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; Karen H. Walson, Children's Healthcare of Atlanta; Paula Vanderford, Doernbecher Children's Hospital; Anthony Lee, Nationwide Children's Hospital; Jesse Bain, Virginia Commonwealth University; Peter Skippen, The University of British Columbia; Ryan Breuer, Women and Children's Hospital of Buffalo; Sarah Tallent, Duke Children's Hospital; Vinay Nadkarni, The Children's Hospital of Philadelphia; Akira Nishisaki, The Children's Hospital of Philadelphia
• Journal Title: Pediatric Critical Care Medicine
• Volume: Volume 18, Number 4
• Publisher: Lippincott, Williams & Wilkins | 2017-04-01, Pages 310-318
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1097/PCC.0000000000001074
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, General
• Keywords: Adolescent; Child; Child, Preschool; Critical Illness; Databases, Factual; Female; Hospital Mortality; Humans; Infant; Infant, Newborn; Intensive Care Units, Pediatric; Intubation, Intratracheal; Length of Stay; Male; Multivariate Analysis; Outcome Assessment (Health Care); Quality Improvement; Respiration, Artificial; Retrospective Studies

Abstract

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.