@article{b18206469d1845e0a85f3c99492eb10b,
title = "Frequency of Desaturation and Association with Hemodynamic Adverse Events during Tracheal Intubations in PICUs",
abstract = "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.",
author = "Simon Li and Hsieh, {Ting Chang} and Rehder, {Kyle J.} and Sholeen Nett and Pradip Kamat and Natalie Napolitano and Turner, {David A.} and Michelle Adu-Darko and Jarvis, {J. Dean} and Conrad Krawiec and Derbyshire, {Ashley T.} and Keith Meyer and Giuliano, {John S.} and Joana Tala and Keiko Tarquinio and Ruppe, {Michael D.} and Sanders, {Ronald C.} and Matthew Pinto and Howell, {Joy D.} and Parker, {Margaret M.} and Gabrielle Nuthall and Michael Shepherd and Guillaume Emeriaud and Yuki Nagai and Osamu Saito and Lee, {Jan Hau} and Simon, {Dennis W.} and Alberto Orioles and Karen Walson and Paula Vanderford and Asha Shenoi and Anthony Lee and Bird, {Geoffrey L.} and Michael Miksa and Graciano, {Ana Lia} and Jesse Bain and Skippen, {Peter W.} and Polikoff, {Lee A.} and Vinay Nadkarni and Akira Nishisaki",
note = "Funding Information: Dr. Napolitano{\textquoteright}s institution received funding from the Agency for Healthcare Research and Quality (AHRQ) (AHRQ R18HS022464, R18HS024511, and AHRQ R03HS021583), Nihon Kohden, CVS Health, Philips/Respi- ronics; consulting/speaking agreements with Aerogen, Draeger, GeNO, and Actuated Medical, and she received funding from American Associa- tion for Respiratory Care and Allergy and Asthma Network (on board of directors both nonprofits and payment for travel to meetings). Dr. Jarvis{\textquoteright} institution received grant funding from AHRQ, and he received support for article research from the AHRQ. Dr. Tala disclosed work for hire. Dr. Howell received funding from UpToDate. Dr. Parker received funding from Society of Critical Care Medicine, Raynes McCarty, and Academic Health Professionals. Dr. Nuthall{\textquoteright}s institution received funding from A+ Trust (used toward the salary of the research nurses who helped to collect data). Dr. Emeriaud{\textquoteright}s institution received funding from the clinical scien- tist award from the Fonds de recherche du Quebec-Sant{\'e} and received funding from Maquet Crit Care. Dr. Lee received funding from KK Wom- AHRQ R18HS022464, R18HS024511, and AHRQ R03HS021583. en{\textquoteright}s and Children{\textquoteright}s Hospital. Dr. Nadkarni received supported by grants Tracheal intubation (TI) is a lifesaving procedure for crit-Dr. Nishisaki{\textquoteright}s institution received funding from AHRQ R03HS021583, ically ill children (1, 2). However, we identified that TI AHRQ R18HS022464, and AHRQ R18HS024511, and he received procedures are often associated with adverse TI-associ-disclosed that they do not have any potential conflicts of interest.support for article research from the AHRQ. The remaining authors have ated events (TIAEs) (3–11). Specifically, our previous multi-For information regarding this article, E-mail address: Nishisaki@email. center study with 15 PICUs revealed 20% of TIs are associated chop.edu with adverse TIAEs and 6% are associated with severe adverse events such as cardiac arrest (1.7% of all TIs) or emesis with aspiration. We have also identified patient, provider, and prac-Objectives: Oxygen desaturation during tracheal intubation is tice factors that are associated with the occurrence of adverse known to be associated with adverse ICU outcomes in critically ill TIAEs. Our ongoing quality improvement (QI) project using children. We aimed to determine the occurrence and severity of a bundled intervention with a checklist has been addressing desaturation during tracheal intubations and the association with patient, provider, and practice-level risk factors to decrease the adverse hemodynamic tracheal intubation–associated events. frequency of adverse TIAEs at a multicenter ICU level (5). Design: Retrospective cohort study as a part of the National Emer- Prior to our study, limited literature has suggested that oxy-gency Airway Registry for Children Network{\textquoteright}s quality improvement gen desaturation is frequently observed during TI in high-risk project from January 2012 to December 2014. emergencies in adults, during neonatal TIs in neonatal ICU, Setting: International PICUs. and during TIs in children with difficult airway (difficult to Patients: Critically ill children younger than 18 years undergoing face mask ventilate or to intubate trachea) (12). However, no primary tracheal intubations in the ICUs. large study has quantified the frequency of oxygen desaturation Interventions: tracheal intubation processes of care and outcomes during TIs in critically ill children in PICUs internationally. were prospectively collected using standardized operational defi- Nor has there been a study published evaluating the associa-nitions. We defined moderate desaturation as oxygen saturation tion of desaturation with adverse TIAEs. Given the importance less than 80% and severe desaturation as oxygen saturation less we have placed on preoxygenation in our practice and the use than 70% during tracheal intubation procedures in children with of new techniques such as apneic oxygenation in emergency initial oxygen saturation greater than 90% after preoxygenation. airway management, it is important to document our current Adverse hemodynamic tracheal intubation–associated event was occurrence of oxygen desaturation during TIs in PICUs. This defined as cardiac arrests, hypo or hypertension requiring inter- will help us to estimate the potential clinical impact of future vention, and dysrhythmia. interventions to minimize desaturation. Publisher Copyright: {\textcopyright} 2017 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.",
year = "2018",
month = jan,
day = "1",
doi = "10.1097/PCC.0000000000001384",
language = "English (US)",
volume = "19",
pages = "e41--e50",
journal = "Pediatric Critical Care Medicine",
issn = "1529-7535",
publisher = "Lippincott Williams and Wilkins",
number = "1",
}