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Peri-Intubation Adverse Events in the Critically Ill Child After Hematopoietic Cell Transplant
Kyle B Lenz1, Akira Nishisaki1, Robert B Lindell1
1Division of Critical Care, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
Insights
Mechanically ventilated children after hematopoietic cell transplant (HCT) did not show increased adverse events during tracheal intubation (TI). This study found no significant association between HCT status and peri-intubation hypoxemia or hemodynamic events.
Area of Science:
- Pediatric Critical Care Medicine
- Hematology/Oncology
- Anesthesiology
Background:
- Mechanically ventilated children post-hematopoietic cell transplant (HCT) face higher morbidity and mortality.
- Tracheal intubation-associated adverse events (TIAEs) and peri-intubation hypoxemia are linked to worse outcomes.
Purpose of the Study:
- To investigate if adverse peri-intubation events occur more frequently in HCT patients compared to non-HCT oncologic or other pediatric intensive care unit (PICU) patients.
- To determine if these events contribute to increased mortality in HCT recipients.
Main Methods:
- Retrospective cohort study of critically ill children undergoing tracheal intubation (TI) between 2014 and 2019.
- Data merged from quality improvement databases and chart review, focusing on HCT-related factors.
- Primary outcome: composite of hemodynamic TIAE (hypotension, hypertension, arrhythmia, cardiac arrest) and/or peri-intubation hypoxemia (SpO2 < 80%).
Main Results:
- 1,931 TI encounters included: 92 (4.8%) post-HCT, 319 (16.5%) with malignancy history, 1,520 (78.7%) neither.
- Post-HCT children were older and more likely to have respiratory failure as an indication for intubation.
- No significant difference in composite adverse events: 16% in HCT vs. 10% in non-HCT malignancy vs. 15% in others (OR 1.32, 95% CI 0.72-2.41, p=0.37 after adjustment).
Conclusions:
- This single-center study found no association between HCT status and increased risk of hemodynamic TIAE or peri-intubation hypoxemia during tracheal intubation.
- The findings suggest that while post-HCT patients have unique challenges, intubation-related adverse events may not be a primary driver of their worse outcomes.
Objectives:
Mechanically ventilated children post-hematopoietic cell transplant (HCT) have increased morbidity and mortality compared with other mechanically ventilated critically ill children. Tracheal intubation-associated adverse events (TIAEs) and peri-intubation hypoxemia universally portend worse outcomes. We investigated whether adverse peri-intubation associated events occur at increased frequency in patients with HCT compared with non-HCT oncologic or other PICU patients and therefore might contribute to increased mortality.
Design:
Retrospective cohort between 2014 and 2019.
Setting:
Single-center academic noncardiac PICU.
Patients:
Critically ill children who underwent tracheal intubation (TI).
Interventions:
None.
Measurements And Main Results:
Data from the local airway management quality improvement databases and Virtual Pediatric Systems were merged. These data were supplemented with a retrospective chart review for HCT-related data, including HCT indication, transplant-related comorbidity status, and patient condition at the time of TI procedure. The primary outcome was defined as the composite of hemodynamic TIAE (hypo/hypertension, arrhythmia, cardiac arrest) and/or peri-intubation hypoxemia (oxygen saturation < 80%) events. One thousand nine hundred thirty-one encounters underwent TI, of which 92 (4.8%) were post-HCT, while 319 (16.5%) had history of malignancy without HCT, and 1,520 (78.7%) had neither HCT nor malignancy. Children post-HCT were older more often had respiratory failure as an indication for intubation, use of catecholamine infusions peri-intubation, and use of noninvasive ventilation prior to intubation. Hemodynamic TIAE or peri-intubation hypoxemia were not different across three groups (HCT 16%, non-HCT with malignancy 10%, other 15). After adjusting for age, difficult airway feature, provider type, device, apneic oxygenation use, and indication for intubation, we did not identify an association between HCT status and the adverse TI outcome (odds ratio, 1.32 for HCT status vs other; 95% CI, 0.72-2.41; p = 0.37).
Conclusions:
In this single-center study, we did not identify an association between HCT status and hemodynamic TIAE or peri-intubation hypoxemia during TI.
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