Objectives: Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. Design: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. Setting: Forty international PICUs participating in the National Emergency Airway Registry for Children. Patients: Critically ill children 0–17 years old who underwent tracheal intubation in a PICU. Interventions: None. Measurements and Main Results: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust se s to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% ( n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58–0.95). The interaction term between ketamine use and indication for shock was not significant ( p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. Conclusions: Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation–associated adverse 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.
The pediatric intensive care unit (ICU) is a complex environment, in which a multidisciplinary team of clinicians (registered nurses, respiratory therapists, and physicians) continually observe and evaluate patient information. Data are provided by multiple, and often physically separated sources, cognitive workload is high, and team communication can be challenging. Our aim is to combine information from multiple monitoring and therapeutic devices in a mobile application, the VitalPAD, to improve the efficiency of clinical decision-making, communication, and thereby patient safety. We observed individual ICU clinicians, multidisciplinary rounds, and handover procedures for 54 h to identify data needs, workflow, and existing cognitive aid use and limitations. A prototype was developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from 15 clinicians. Features included map overviews of the ICU showing clinician assignment, patient status, and respiratory support; patient vital signs; a photo-documentation option for arterial blood gas results; and team communication and reminder functions. Clinicians reported the prototype to be an intuitive display of vital parameters and relevant alerts and reminders, as well as a user-friendly communication tool. Future work includes implementation of a prototype, which will be evaluated under simulation and real-world conditions, with the aim of providing ICU staff with a monitoring device that will improve their daily work, communication, and decision-making capacity. Mobile monitoring of vital signs and therapy parameters might help improve patient safety in wards with single-patient rooms and likely has applications in many acute and critical care settings.
Central vascular access is sometimes required for hemodynamic monitoring and infusion of fluids and medications in the pediatric emergency department. In many cases, it is attempted after failed peripheral venous and intraosseous access. Some evidence exists demonstrating benefits of ultrasound (US)-guided central vascular cannulation in adults in emergency departments. With appropriate education in its use, US-guided cannulation of central veins in children is likely to be associated with less complications and greater success. In the pediatric emergency department, the femoral vein is the most practical central venous cannulation site. A sound educational and quality assurance program is necessary for US-guided cannulation in the pediatric emergency department.
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Davis, Alan L. MD, MPH, FAAP, FCCM; Carcillo, Joseph A. MD; Aneja, Rajesh K. MD; Deymann, Andreas J. MD; Lin, John C. MD; Nguyen, Trung C. MD; Okhuysen-Cawley, Regina S. MD, FAAP; Relvas, Monica S. MD, FAAP, MSHA, FCCM; Rozenfeld, Ranna A. MD, FCCM; Skippen, Peter W. MD, MBBS, FRCPC; Stojadinovic, Bonnie J. DNP, CPNP; Williams, Eric A. MD, MS, MMM; Yeh, Tim S. MD, MCCM; Balamuth, Fran MD; Brierley, Joe MD, MA; de Caen, Allan R. MD; Cheifetz, Ira M. MD, FCCM; Choong, Karen MSc, MB, Bch; Conway, Edward Jr MD, MS, FCCM; Cornell, Timothy MD; Doctor, Allan MD; Dugas, Marc-Andre MD, MSc; Feldman, Jonathan D. MD; Fitzgerald, Julie C. MD, PhD; Flori, Heidi R. MD; Fortenberry, James D. MD, MCCM; Graciano, Ana Lia MD, FAAP, FCCM; Greenwald, Bruce M. MD, FAAP, FCCM; Hall, Mark W. MD, FCCM; Han, Yong Yun MD; Hernan, Lynn J. MD; Irazuzta, Jose E. MD, FCCM; Iselin, Elizabeth MD; van der Jagt, Elise W. MD, MPH, FAAP, SFHM; Jeffries, Howard E. MD, MBA; Kache, Saraswati MD; Katyal, Chhavi MD; Kissoon, Niranjan MD, MCCM, FCCM; Kon, Alexander A. MD, FCCM; Kutko, Martha C. MD, FCCM; MacLaren, Graeme MD, FCCM; Maul, Timothy PhD; Mehta, Renuka MD, MBBS, FAAP; Odetola, Fola MD, MPH; Parbuoni, Kristine BCPS, PharmD; Paul, Raina MD; Peters, Mark J. MD, PhD; Ranjit, Suchitra MD, FCCM; Reuter-Rice, Karin E. PhD, CPNP-AC, FCCM; Schnitzler, Eduardo J. MD; Scott, Halden F. MD; Torres, Adalberto Jr MD, MS, FCCM; Weingarten-Abrams, Jacki MD; Weiss, Scott L. MD; Zimmerman, Jerry J. MD, PhD, FCCM; Zuckerberg, Aaron L. MD Author Information
Objectives: Oxygen desaturation during tracheal intubation is known to be associated with adverse ICU outcomes in critically ill children. We aimed to determine the occurrence and severity of desaturation during tracheal intubations and the association with adverse hemodynamic tracheal intubation–associated events. Design: Retrospective cohort study as a part of the National Emergency Airway Registry for Children Network’s quality improvement project from January 2012 to December 2014. Setting: International PICUs. Patients: Critically ill children younger than 18 years undergoing primary tracheal intubations in the ICUs. Interventions: tracheal intubation processes of care and outcomes were prospectively collected using standardized operational definitions. We defined moderate desaturation as oxygen saturation less than 80% and severe desaturation as oxygen saturation less than 70% during tracheal intubation procedures in children with initial oxygen saturation greater than 90% after preoxygenation. Adverse hemodynamic tracheal intubation–associated event was defined as cardiac arrests, hypo or hypertension requiring intervention, and dysrhythmia. Measurements and Main Results: A total of 5,498 primary tracheal intubations from 31 ICUs were reported. Moderate desaturation was observed in 19.3% associated with adverse hemodynamic tracheal intubation–associated events (9.8% among children with moderate desaturation vs 4.4% without desaturation; p < 0.001). Severe desaturation was observed in 12.9% of tracheal intubations, also significantly associated with hemodynamic tracheal intubation–associated events. After adjusting for patient, provider, and practice factors, the occurrence of moderate desaturation was independently associated with hemodynamic tracheal intubation–associated events: adjusted odds ratio 1.83 (95% CI, 1.34–2.51; p < 0.001). The occurrence of severe desaturation was also independently associated with hemodynamic tracheal intubation–associated events: adjusted odds ratio 2.16 (95% CI, 1.54–3.04; p < 0.001). Number of tracheal intubation attempts was also significantly associated with the frequency of moderate and severe desaturations ( p < 0.001). Conclusions: In this large tracheal intubation quality improvement database, we found moderate and severe desaturation are reported among 19% and 13% of all tracheal intubation encounters. Moderate and severe desaturations were independently associated with the occurrence of adverse hemodynamic events. Future quality improvement interventions may focus to reduce desaturation events.
