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Effect of Location on Tracheal Intubation Safety in Cardiac Disease-Are Cardiac ICUs Safer?
Eleanor A Gradidge1, Adnan Bakar2, David Tellez1
1Division of Pediatric Critical Care, Phoenix Children's Hospital, Phoenix, AZ.
Insights
Pediatric cardiac ICUs did not show lower rates of tracheal intubation complications compared to noncardiac PICUs in children with heart disease. However, cardiac ICUs had more frequent desaturations during intubation procedures.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiology
- Anesthesiology
Background:
- Tracheal intubation in critically ill children with cardiac disease carries risks.
- Understanding variations in intubation-associated events between specialized cardiac pediatric intensive care units (PICUs) and general PICUs is crucial for quality improvement.
Purpose of the Study:
- To compare tracheal intubation-associated events and process variances between pediatric cardiac ICUs and noncardiac PICUs in children with cardiac conditions.
- To identify potential differences in intubation safety and efficiency in specialized versus general pediatric critical care settings.
Main Methods:
- Retrospective cohort study utilizing the National Emergency Airway Registry for Children (NEAR) database.
- Analysis of 1,502 tracheal intubations in children with cardiac disease across 36 PICUs (5 cardiac, 31 noncardiac) from July 2012 to March 2016.
Main Results:
- Overall adverse tracheal intubation-associated event rates were similar between cardiac ICUs and noncardiac PICUs (16% vs 19%; aOR, 0.74; P=0.069).
- Cardiac ICUs showed significantly higher rates of oxygen desaturation during intubation (aOR, 1.61; P=0.002).
- A sensitivity analysis indicated lower odds of adverse events in cardiac ICUs compared to mixed ICUs (aOR, 0.71; P=0.033).
Conclusions:
- Pediatric cardiac ICUs did not demonstrate lower rates of adverse tracheal intubation-associated events compared to noncardiac PICUs for children with cardiac disease.
- Despite similar overall event rates, increased desaturation in cardiac ICUs warrants further investigation into specific care practices.
Objectives:
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.
Design:
Retrospective cohort study using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children).
Setting:
Thirty-six PICUs (five cardiac ICUs, 31 noncardiac ICUs) from July 2012 to March 2016.
Patients:
Children with medical or surgical cardiac disease who underwent intubation in an ICU.
Interventions:
None.
Measurements And Main Results:
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).
Conclusions:
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.
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