High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence

Preston Dean, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States. Electronic address: preston.dean@cchmc.org.
Gary Geis, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States. Electronic address: gary.geis@cchmc.org.
Erin F. Hoehn, Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Division of Emergency Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States. Electronic address: erin.hoehn@uhhospitals.org.
Andrew J. Lautz, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States; Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. Electronic address: andrew.lautz@cchmc.org.
Katherine Edmunds, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States. Electronic address: katherine.edmunds@cchmc.org.
Ashish Shah, Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States. Electronic address: ashah@health.ucsd.edu.
Yin Zhang, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. Electronic address: yin.zhang@cchmc.org.
Mary Frey, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. Electronic address: mary.frey@cchmc.org.
Stephanie Boyd, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States. Electronic address: stephanie.boyd@cchmc.org.
Joshua Nagler, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States. Electronic address: joshua.nagler@childrens.harvard.edu.
Kelsey A. Miller, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States. Electronic address: kelsey.miller@childrens.harvard.edu.
Tara L. Neubrand, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States; Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, United States. Electronic address: tneubrand@salud.unm.edu.
Natasha Cabrera, Section of Emergency Medicine, Children's Hospital Colorado, Aurora, CO, United States.
Tara M. Kopp, Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States. Electronic address: tara.kopp.1@louisville.edu.
Esper Wadih, Division of Emergency Medicine, Norton Children's Hospital, University of Louisville School of Medicine, Louisville, KY, United States. Electronic address: esper.wadih@louisville.edu.
Nirupama Kannikeswaran, Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States. Electronic address: nkannike@dmc.org.
Audrey VanDeWall, Division of Emergency Medicine, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, United States. Electronic address: avandewa@dmc.org.
Elizabeth K. Hewett Brumberg, Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States. Electronic address: elizabeth.hewett@chp.edu.
Aaron Donoghue, Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States. Electronic address: donoghue@chop.edu.
Lauren Palladino, Division of Emergency Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States. Electronic address: palladinol@chop.edu.
Karen J. O'Connell, Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States. Electronic address: koconnel@childrensnational.org.
Malek Mazzawi, Division of Emergency Medicine, Children's National Hospital, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States. Electronic address: mmazzawi2@childrensnational.org.
Derek Chi Tam, Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States. Electronic address: dtam@health.ucsd.edu.
Matthew Murray, Division of Emergency Medicine, Rady Children's Hospital, University of California San Diego, San Diego, CA, United States. Electronic address: mpmurray@health.ucsd.edu.
Benjamin Kerrey, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States. Electronic address: benjamin.kerrey@cchmc.org.

Document Type

Journal Article

Publication Date

6-14-2023

Journal

Resuscitation

DOI

10.1016/j.resuscitation.2023.109875

Keywords

ECMO; Emergency Department; Paediatrics; Peri-intubation cardiac arrest; Tracheal intubation

Abstract

BACKGROUND: Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS: We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS: Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS: In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.

Department

Pediatrics

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