From the, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
the, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
Acad Emerg Med. 2020 Dec;27(12):1241-1248. doi: 10.1111/acem.14128. Epub 2020 Oct 3.
The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED).
This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria.
Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively.
We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.
危重病儿围插管期心脏骤停的危险因素尚不完全清楚。本研究的目的是在儿科急诊室（PED）中确定气管插管期间恶化的生理危险因素。
这是一项对 PED 中接受紧急气管插管的患者进行的回顾性队列研究。使用已发表的文献和专家意见，一个多学科小组为围插管期停搏制定了高危标准：1）低血压，2）对心功能障碍的关注，3）持续低氧血症，4）严重代谢性酸中毒（pH <7.1），5）自主循环恢复后（ROSC），和 6）哮喘状态。我们对 PED 中插管患者的电子病历进行了结构化审查。主要结局是围插管期停搏。次要结局包括气管插管成功率、体外膜氧合（ECMO）激活和院内死亡率。我们比较了符合一项或多项高危标准与不符合任何高危标准的患者的结局。
至少符合一项高危标准的患者中，围插管期心脏骤停发生率为 5.6%，而无一符合高危标准的患者为 0%（5.6%差异，95%置信区间[CI]为 1.0 至 18.1，p=0.028）。符合至少一项标准的患者在 PED 中有更高的任何插管后心脏骤停发生率（11.1%比 0%，11.1%差异，95%CI为 4.1 至 25.3，p=0.0007），院内死亡率（25%比 2.3%，22.7%差异，95%CI为 11.0 至 38.9，p<0.0001），ECMO 激活（8.3%比 0%，8.3%差异，95%CI为 2.5 至 21.8，p=0.004），以及首次插管成功率较低（47.2%比 66.1%，-18.9%差异，95%CI为-35.5 至-1.5，p=0.038）。
我们已经制定了能够成功识别 PED 中生理困难气道的标准。低血压、持续低氧血症、心功能障碍、严重代谢性酸中毒、哮喘状态或 ROSC 后患儿发生围插管期心脏骤停和院内死亡率的风险更高。需要进一步的多中心研究来验证我们的发现。
