不良气管插管相关事件与儿科重症监护病房结局之间的关系。
Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes.
作者信息
Parker Margaret M, Nuthall Gabrielle, Brown Calvin, Biagas Katherine, Napolitano Natalie, Polikoff Lee A, Simon Dennis, Miksa Michael, Gradidge Eleanor, Lee Jan Hau, Krishna Ashwin S, Tellez David, Bird Geoffrey L, Rehder Kyle J, Turner David A, Adu-Darko Michelle, Nett Sholeen T, Derbyshire Ashley T, Meyer Keith, Giuliano John, Owen Erin B, Sullivan Janice E, Tarquinio Keiko, Kamat Pradip, Sanders Ronald C, Pinto Matthew, Bysani G Kris, Emeriaud Guillaume, Nagai Yuki, McCarthy Melissa A, Walson Karen H, Vanderford Paula, Lee Anthony, Bain Jesse, Skippen Peter, Breuer Ryan, Tallent Sarah, Nadkarni Vinay, Nishisaki Akira
机构信息
1Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children's Hospital, Stony Brook, NY. 2Department of Pediatrics, Pediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand. 3Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. 4Department of Pediatrics, Columbia University/New York Presbyterian Hospital, New York, NY. 5Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, PA. 6Division of Pediatric Critical Care Medicine, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Providence, RI. 7Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 8Department of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore, Bronx, NY. 9Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ. 10Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore. 11Division of Pediatric Critical Care, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KY. 12Department of Child Health University of Arizona College of Medicine, Department of Critical Care Phoenix Children's Hospital, Phoenix, AZ. 13Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 14Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC. 15Pediatric Critical Care Medicine, The University of Virginia Children's Hospital, Charlottesville, VA. 16Division of Pediatric Critical Care, Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH. 17Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, PA. 18Pediatric Critical Care Medicine, Nicklaus Children's Hospital, Miami Children's Health System, Miami, FL. 19Critical Care Medicine, Department of Pediatrics, Yale Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT. 20Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Louisville, KY. 21Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA. 22Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas College of Medicine, Little Rock, AR. 23Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital Westchester Medical Center, Valhalla, NY. 24Pediatric Critical Care Medicine, Medical City Children's Hospital, Dallas, TX. 25Department of Pediatrics, Sainte-Justine University Hospital Center, Montreal, QC, Canada. 26Department of Emergency Medicine, Tokyo Metropolitan Children's Medical Centre, Tokyo, Japan. 27Department of Critical Care Medicine, Children's Hospital of Pittsburgh at University of Pittsburgh Medical Center, Pittsburgh, PA. 28Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, GA. 29Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR. 30Division of Critical Care, Nationwide Children's Hospital, Columbus, OH. 31Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA. 32Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada. 33Division of Critical Care, Department of Pediatrics, Women & Children's Hospital of Buffalo, Buffalo, NY. 34Division of Pediatric Cardiac Intensive Care, Department of Pediatric Critical Care Medicine, Duke Children's Hospital & Health Center, Durham, NC.
出版信息
Pediatr Crit Care Med. 2017 Apr;18(4):310-318. doi: 10.1097/PCC.0000000000001074.
OBJECTIVE
Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality.
STUDY DESIGN
Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%.
SETTING
PICUs participating in NEAR4KIDS.
PATIENTS
All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed.
MEASUREMENTS AND MAIN RESULTS
Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58-229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1-7 yr and 18% for 8-17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4-21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24-2.60; p = 0.002), after adjusted for patient confounders.
CONCLUSIONS
Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.
目的
在儿科重症监护病房（PICU）进行气管插管是一项常见操作，常伴有不良事件。本研究旨在评估气管插管相关事件或血氧饱和度降低等即时事件与ICU结局（住院时间、机械通气时间和死亡率）之间的关联。
研究设计
采用前瞻性队列研究，于2013年1月至2015年6月对35个PICU使用多中心气管插管质量改进数据库（儿童国家紧急气道注册系统：NEAR4KIDS）。血氧饱和度降低定义为血氧饱和度（Spo2）低于80%。
研究地点
参与NEAR4KIDS的PICU。
研究对象
分析所有年龄小于18岁且有ICU结局数据的接受初次气管插管的患者。
测量指标及主要结果
共进行了5504次气管插管，每个研究点气管插管次数中位数为108次（四分位间距为58 - 229次）。892例（16%）报告了至少一次气管插管相关事件，其中364例（6.6%）为严重气管插管相关事件。婴儿发生气管插管相关事件或血氧饱和度降低的频率高于年长患者（婴儿为48%，1 - 7岁儿童为34%，8 - 17岁儿童为18%）。单因素分析中，气管插管相关事件或血氧饱和度降低的发生与机械通气时间延长（5天对3天；p < 0.001）和PICU住院时间延长（14天对11天；p < 0.001）相关，但与PICU死亡率无关。严重气管插管相关事件的发生与机械通气时间延长（5天对4天；p < 0.003）、PICU住院时间延长（15天对12天；p < 0.035）以及PICU死亡率（19.9%对9.6%；p < 0.0001）相关。多因素分析中，在对患者混杂因素进行校正后，气管插管相关事件或血氧饱和度降低的发生与机械通气时间显著延长（增加12%；95%置信区间为4% - 21%；p = 0.004）相关，严重气管插管相关事件与PICU死亡率增加独立相关（比值比 = 1.80；95%置信区间为1.24 - 2.60；p = 0.00）。
结论
气管插管相关不良事件和血氧饱和度降低在危重症儿童中很常见，且与机械通气时间延长相关。严重气管插管相关事件与更高的ICU死亡率相关。可能需要考虑采取如气管插管清单、使用无呼吸氧合和视频喉镜等潜在干预措施来减少气管插管相关事件和氧饱和度降低，以改善ICU结局。
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