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Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective
Carine Foz1, Steven J Staffa2, Raymond Park2
1Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology and Pain Medicine, American University of Beirut-Medical Center, Beirut, Lebanon.
Insights
Difficult tracheal intubation (DTI) in children with congenital heart disease occurred in 0.96% of cases. While DTI required more attempts, it did not significantly impact peri-intubation hemodynamics but did increase hospital stay.
Area of Science:
- Pediatric Anesthesiology
- Cardiology
- Critical Care Medicine
Background:
- Managing difficult tracheal intubation (DTI) in pediatric patients with congenital heart disease (CHD) presents unique challenges.
- Assessing the incidence of DTI and its associated complications in this vulnerable population is crucial for improving patient outcomes.
Purpose of the Study:
- To evaluate the incidence of difficult tracheal intubation in children with congenital heart disease.
- To compare perioperative complications and outcomes between patients with and without difficult tracheal intubation.
Main Methods:
- A retrospective cohort study was conducted, analyzing 6014 patient encounters involving cardiac procedures.
- Propensity score matching was used to compare 58 cases of difficult tracheal intubation with 116 controls.
- Multivariable regression models analyzed outcomes including intubation attempts, hemodynamic stability, and hospital length of stay.
Main Results:
- The incidence of difficult tracheal intubation was 0.96%.
- Patients with difficult tracheal intubation required significantly more intubation attempts (OR=2; P<0.001).
- No significant differences in peri-intubation hemodynamic stability were observed; however, patients with difficult tracheal intubation had a longer postoperative hospital stay (12.1 vs 7.9 days; P=0.004).
Conclusions:
- Difficult tracheal intubation in pediatric patients with congenital heart disease is associated with increased intubation attempts and longer hospital stays, but not necessarily with hemodynamic instability.
- Effective management strategies, including understanding cardiac physiology and early use of indirect intubation techniques, can mitigate risks associated with difficult tracheal intubation.
Background And Objective:
Management of difficult tracheal intubation during induction of anesthesia in children with congenital heart disease is challenging. The aim of this study is to evaluate the incidence of difficult tracheal intubation in patients with congenital heart disease and compare the incidence of perioperative complications and outcomes in patients with and without difficult tracheal intubation.
Design:
Retrospective cohort study.
Setting:
Tertiary Children's Hospital.
Participants:
6858 patient-encounters including cardiac diagnostic, interventional or surgical procedures from 2012 to 2018 were reviewed.
Exclusion Criteria:
age > 18 years, endotracheal tube or tracheostomy in-situ.
Methods/Interventions:
Patients' demographics, number and methods of intubation, peri-intubation hemodynamics, intensive care unit and postoperative hospital length of stay were recorded. Multivariable mixed-effects median, logistic, ordinal, and multinomial regression modeling were implemented to analyze outcomes in the matched sets.
Results:
Of the 6014 encounters examined in the study, the incidence of DTI was 0.96% and all 58 difficult tracheal intubations (DTI) were matched using 1:2 propensity score matching to 116 non-DTI encounters. Number of intubation attempts was significantly higher among patients with difficult tracheal intubation (ordinal logistic regression odds ratio = 2; 95% CI; 1.3, 2.7; P < 0.001). No significant differences in peri-intubation hemodynamic stability were noted. Patients with difficult tracheal intubation had longer postoperative hospital length of stay (median = 12.1 vs 7.9 days, coef. = 4; 95% CI: 1.3, 6.8; P = 0.004) than patients without.
Conclusion:
Despite a higher number of intubation attempts, our study shows no major differences in the peri-intubation hemodynamics in patients with and without difficult tracheal intubation. This risk can be mitigated by a good understanding of cardiac physiology, management of hemodynamics, and early use of an indirect intubation technique to maximize first attempt success.
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