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Risk Factors for Peri-Intubation Cardiac Arrest in Pediatric Cardiac Intensive Care Patients: A Multicenter Study
Ivie D Esangbedo1, Jonathan Byrnes2,3, Katie Brandewie2
1Division of Critical Care Medicine, Cardiac Intensive Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
Insights
Critically ill pediatric cardiac patients undergoing endotracheal intubation (EI) face a high risk of cardiac arrest, particularly those with systemic ventricle systolic dysfunction. This study highlights elevated peri-intubation cardiac arrest and mortality rates in this vulnerable population.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiology
- Anesthesiology
Background:
- Endotracheal intubation (EI) can precipitate hemodynamic instability, especially in pediatric patients with cardiac conditions.
- Limited data exists on the frequency and risk factors for hemodynamic complications, including cardiac arrest, during EI in critically ill children with heart disease.
Purpose of the Study:
- To determine the frequency of peri-intubation cardiac arrest in critically ill pediatric cardiac patients.
- To identify risk factors associated with peri-intubation cardiac arrest in this specific patient group.
Main Methods:
- A multicenter retrospective cohort study was conducted across three US pediatric cardiac intensive care units.
- Data from 186 endotracheal intubation events in 151 critically ill pediatric cardiac patients (January 2015–December 2017) were analyzed.
- Clinical variables related to patients, providers, and the procedure were assessed for association with peri-intubation cardiac arrest.
Main Results:
- The study observed a 7% rate of peri-intubation cardiac arrest and a 1.6% peri-intubation mortality rate.
- Patients with moderate or severe systemic ventricle systolic dysfunction had a significantly higher peri-intubation cardiac arrest rate (20.7%).
- Key risk factors identified include: systemic ventricle systolic dysfunction, pre-intubation hypotension, elevated lactate, lower pH, and intra-intubation oxygen desaturations.
Conclusions:
- Peri-intubation cardiac arrest rates in critically ill pediatric cardiac patients are higher than previously reported for both cardiac and non-cardiac pediatric populations.
- Significant systolic dysfunction of the systemic ventricle is a major risk factor for peri-intubation cardiac arrest.
- High peri-intubation mortality underscores the critical nature of these events in this cohort.
Objectives:
Endotracheal intubation is associated with hemodynamic adverse events, including cardiac arrest, especially in patients with cardiac disease. There are only a few studies that have evaluated the rate of and risk factors for endotracheal intubation hemodynamic complications in critically ill pediatric patients. Although some of these studies have assessed hemodynamic complications during intubation in pediatric cardiac patients, the frequency of and risk factors for peri-intubation cardiac arrest have not been adequately described in high acuity cardiac patients. This study aims to describe the frequency of and risk factors for peri-intubation cardiac arrest in critically ill pediatric cardiac patients admitted to specialized cardiac ICUs.
Design:
Multicenter retrospective cohort study.
Setting:
Three pediatric cardiac ICUs in the United States.
Patients:
Critically ill pediatric patients with congenital or acquired heart disease requiring endotracheal intubation.
Interventions:
None.
Measurements And Main Results:
Endotracheal intubations performed in three cardiac ICUs between January 2015 and December 2017 were reviewed. Clinical variables-including data on patients, clinical providers, and procedure-were evaluated for their association with peri-intubation cardiac arrest. There was a total of 186 intubation events studied, occurring in 151 individual (index) patients. The rates of peri-intubation cardiac arrest and peri-intubation mortality in this cohort were 7% and 1.6%, respectively. Among those patients with moderate or severe systolic dysfunction of the systemic ventricle, peri-intubation cardiac arrest rate was 20.7%. Statistically significant risk factors for peri-intubation cardiac arrest included: significant systolic dysfunction of the systemic ventricle, pre-intubation hypotension, pre-intubation lactate elevation, lower pre-intubation pH, and documented oxygen desaturations (> 10%) during intubation procedure.
Conclusions:
Our most significant finding was a peri-intubation cardiac arrest rate which was much higher than previously published rates for both cardiac and noncardiac children who underwent endotracheal intubation in ICUs. Peri-intubation mortality was also high in our cohort. Regarding risk factors for peri-intubation arrest, significant systolic dysfunction of the systemic ventricle was strongly associated with cardiac arrest in this cohort.
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