Abstract Introduction Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease. Materials and methods We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation. Results A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease. Conclusions The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
Objectives: Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU. Design: A retrospective cohort study of a multicenter pediatric airway quality improvement registry. Settings: 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: Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015. Interventions: None. Measurements and Main Results: Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09–2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99–2.47; p = 0.054). A sensitivity analysis in propensity score–matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00–1.02; p = 0.036). Conclusions: Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.
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. Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children). Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016. Children with medical or surgical cardiac disease who underwent intubation in an ICU. None. 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). 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.
Objectives To describe the epidemiology of extubation failure and identify risk factors for its occurrence in a multicenter population of neonates undergoing surgery for congenital heart disease. Study design We conducted a prospective observational study of neonates ≤30 days of age who underwent cardiac surgery at 7 centers within the US in 2015. Extubation failure was defined as reintubation within 72 hours of the first planned extubation. Risk factors were identified with the use of multivariable logistic regression analysis and reported as OR with 95% CIs. Multivariable logistic regression analysis was conducted to examine the relationship between extubation failure and worse clinical outcome, defined as hospital length of stay in the upper 25% or operative mortality. Results We enrolled 283 neonates, of whom 35 (12%) failed their first extubation at a median time of 7.5 hours (range 1-70 hours). In a multivariable model, use of uncuffed endotracheal tubes (OR 4.6; 95% CI 1.8-11.6) and open sternotomy of 4 days or more (OR 4.8; 95% CI 1.3-17.1) were associated independently with extubation failure. Accordingly, extubation failure was determined to be an independent risk factor for worse clinical outcome (OR 5.1; 95% CI 2-13). Conclusions In this multicenter cohort of neonates who underwent surgery for congenital heart disease, extubation failure occurred in 12% of cases and was associated independently with worse clinical outcome. Use of uncuffed endotracheal tubes and prolonged open sternotomy were identified as independent and potentially modifiable risk factors for the occurrence of this precarious complication.
Objectives: Poor communication during interfacility transfer to the PICU can harm critically ill children. Structured handoff communication can prevent harm; however, the landscape of interfacility referral communication practices across PICUs is unknown. Our objective was to describe interfacility referral communication practices among U.S. PICUs to begin identifying potential improvement opportunities. Design: Mixed methods study including a cross-sectional survey and semi-structured interviews. Setting: U.S. PICUs with greater than or equal to 10 beds in 2023. Participants: Clinical/administrative PICU leaders. Interventions: None. Measurements and Main Results: Sixty surveys with greater than 70% completed questions were returned from 170 invited participants (35% response rate). Respondents were mainly pediatric critical care medicine division chiefs (48%) or PICU medical directors (32%). PICUs in all U.S. continental regions were represented, which had a median of 1200 (interquartile range [IQR], 1000–1500) admissions per year, of which 29.5% (IQR, 15–39%) were patients directly transferred from other institutions. In 93% of PICUs, a verbal interfacility handoff occurs between the referring clinician and a PICU physician; however, only 24% were always guided by a standard communication tool. In 72% of PICUs, medical records were only sometimes available before patient arrival. Semi-structured interviews with seven volunteer respondents revealed the following themes: 1) standardizing communication can result in organized and efficient handoffs but may also result in inefficiencies, 2) trained staff dedicated to interfacility referrals will improve communication quality, 3) integration of handoff information into the electronic health record will improve dissemination and decrease PICU physicians’ workload, and 4) implementing a structured process will require staff support to change current workflows. Conclusions: Referral communication for interfacility patient transfers to the PICU occurred mainly through unstructured verbal handoffs between referring clinicians and PICU physicians. PICU leaders identified several potential benefits and challenges of standardizing interfacility referral communication.
Reye syndrome is a rare and potentially life-threatening disease characterized by liver failure and hepatic encephalopathy. Multiple possible etiologies have been suggested, but only aspirin (acetylsalicylic acid) has been statistically proven to be a causative factor. We describe a case of Reye syndrome secondary to influenza A virus.A 2-year-old male with a recent history of influenza-like symptoms presented with neurologic deterioration. He had elevated liver enzymes, hyperammonemia, elevated creatinine, and hypoglycemia. Liver biopsy showed microvesicular steatosis consistent with Reye syndrome. He was given supportive care and recovered after 17 days with normalization of metabolic derangements. At 4-month follow-up, the patient had reached age-specific developmental milestones.The incidence of Reye syndrome has decreased since 1980 when the Centers for Disease Control and Prevention issued a warning against aspirin use in children. Consequently, any new incidence of Reye syndrome warrants investigation of other etiologies. This case adds to the evidence that causes other than aspirin can result in Reye syndrome.
Tracheal intubation carries a high risk of adverse events. The current literature is unclear regarding the "New Trainee Effect" on tracheal intubation safety in the PICU. We evaluated the effect of the timing of the PICU fellow academic cycle on tracheal intubation associated events. We hypothesize 1) PICUs with pediatric critical care medicine fellowship programs have more adverse tracheal intubation associated events during the first quarter (July-September) of the academic year compared with the rest of the year and 2) tracheal intubation associated event rates and first attempt success performed by pediatric critical care medicine fellows improve through the 3-year clinical fellowship. Retrospective cohort study. Thirty-seven North American PICUs participating in National Emergency Airway Registry for Children. All patients who underwent tracheal intubations in the PICU from July 2013 to June 2017. None. The occurrence of any tracheal intubation associated events during the first quarter of the academic year (July-September) was compared with the rest in four different types of PICUs: PICUs with fellows and residents, PICUs with fellows only, PICUs with residents only, and PICUs without trainees. For the second hypothesis, tracheal intubations by critical care medicine fellows were categorized by training level and quarter for 3 years of fellowship (i.e., July-September of 1st yr pediatric critical care medicine fellowship = first quarter, October-December of 1st yr pediatric critical care medicine fellowship = second quarter, and April-June during 3rd year = 12th quarter). A total of 9,774 tracheal intubations were reported. Seven-thousand forty-seven tracheal intubations (72%) were from PICUs with fellows and residents, 525 (5%) with fellows only, 1,201 (12%) with residents only, and 1,001 (10%) with no trainees. There was no difference in the occurrence of tracheal intubation associated events in the first quarter versus the rest of the year (all PICUs: July-September 14.9% vs October-June 15.2%; p = 0.76). There was no difference between these two periods in each type of PICUs (all p ≥ 0.19). For tracheal intubations by critical care medicine fellows (n = 3,836), tracheal intubation associated events significantly decreased over the fellowship: second quarter odds ratio 0.64 (95% CI, 0.45-0.91), third quarter odds ratio 0.58 (95% CI, 0.42-0.82), and 12th quarter odds ratio 0.40 (95% CI, 0.24-0.67) using the first quarter as reference after adjusting for patient and device characteristics. First attempt success significantly improved during fellowship: second quarter odds ratio 1.39 (95% CI, 1.04-1.85), third quarter odds ratio 1.59 (95% CI, 1.20-2.09), and 12th quarter odds ratio 2.11 (95% CI, 1.42-3.14). The New Trainee Effect in tracheal intubation safety outcomes was not observed in various types of PICUs. There was a significant improvement in pediatric critical care medicine fellows' first attempt success and a significant decline in tracheal intubation associated event rates, indicating substantial skills acquisition throughout pediatric critical care medicine fellowship.
Introduction: More than a quarter million children are hospitalized in intensive care units (ICUs) each year. Pediatric ICUs (PICUs) are specialized ICUs that provide for unique care needs of children, which includes pediatric specialists, family-centered care models, and pediatric-specific resources. Over the past 40 years there have been an increase in number of PICUs and PICU beds. The largest increase in PICUs was 43% between 1979 and 1988 when the specialty was further defined. This slowed in the late 1990s, and there was a decrease in PICUs over the next 15 years. Although the characteristics of PICUs has been well-described, the change in location of PICUs over time is an important factor in the ease of access for critically ill children. For various reasons, a multitude of units have opened, closed, or moved over the last few decades, thereby affecting the distance a child must travel to access a PICU. Geographic access to PICUs is also essential to understanding the inequities that affect the survival and outcomes of children who present to community hospitals. For this study, we conducted a geospatial analysis to analyze the change in distribution of PICUs across the United States over the past 22 years. Methods: Lists of PICUs were used from three different years (2001, 2016 and 2023). These lists were compiled from multiple sources. PICUs included in analysis were limited to those in the contiguous United States. We used straight-line distances of PICUs, and the closest location was selected using the shortest, geodesic straight-line distance. Polygons were created around each PICU location to indicate all locations within a given polygon are closer to the PICU inside that polygon than any other PICU location. Maps were generated using ArcGIS Pro software. Results: The minimum distance between PICUs was 0 miles for all years, and the maximum distance increased from 866 miles to 928 miles at the first time interval. The median distance did not vary significantly with an increase from 12.5 (IQR 4.5, 37.1) to 12.8 (IQR 4.9, 36.2) to 13.3 (IQR 5.2, 36.0) miles for 2001, 2016, and 2023, respectively. Conclusions: By observing and mapping PICU locations, governments and healthcare systems can better anticipate needs and ensure that all children have access to life-saving critical care.
