High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence
ECMO; Emergency Department; Paediatrics; Peri-intubation cardiac arrest; Tracheal intubation
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.
Dean, Preston; Geis, Gary; Hoehn, Erin F.; Lautz, Andrew J.; Edmunds, Katherine; Shah, Ashish; Zhang, Yin; Frey, Mary; Boyd, Stephanie; Nagler, Joshua; Miller, Kelsey A.; Neubrand, Tara L.; Cabrera, Natasha; Kopp, Tara M.; Wadih, Esper; Kannikeswaran, Nirupama; VanDeWall, Audrey; Hewett Brumberg, Elizabeth K.; Donoghue, Aaron; Palladino, Lauren; O'Connell, Karen J.; Mazzawi, Malek; Tam, Derek Chi; Murray, Matthew; and Kerrey, Benjamin, "High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence" (2023). GW Authored Works. Paper 2718.