RESUMO
OBJECTIVES: Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. DESIGN: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. SETTING: Forty international PICUs participating in the National Emergency Airway Registry for Children. PATIENTS: Critically ill children 0-17 years old who underwent tracheal intubation in a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. CONCLUSIONS: Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.
Assuntos
Analgésicos/uso terapêutico , Hemodinâmica/efeitos dos fármacos , Intubação Intratraqueal/métodos , Ketamina/uso terapêutico , Choque/epidemiologia , Adolescente , Fatores Etários , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Criança , Pré-Escolar , Estado Terminal , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Ketamina/administração & dosagem , Ketamina/efeitos adversos , Masculino , Estudos RetrospectivosRESUMO
OBJECTIVES: Cricoid pressure is often used to prevent regurgitation during induction and mask ventilation prior to high-risk tracheal intubation in critically ill children. Clinical data in children showing benefit are limited. Our objective was to evaluate the association between cricoid pressure use and the occurrence of regurgitation during tracheal intubation for critically ill children in PICU. DESIGN: A retrospective cohort study of a multicenter pediatric airway quality improvement registry. SETTINGS: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Children (< 18 yr) with initial tracheal intubation using direct laryngoscopy in PICUs between July 2010 and December 2015. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multivariable logistic regression analysis was used to evaluate the association between cricoid pressure use and the occurrence of regurgitation while adjusting for underlying differences in patient and clinical care factors. Of 7,825 events, cricoid pressure was used in 1,819 (23%). Regurgitation was reported in 106 of 7,825 (1.4%) and clinical aspiration in 51 of 7,825 (0.7%). Regurgitation was reported in 35 of 1,819 (1.9%) with cricoid pressure, and 71 of 6,006 (1.2%) without cricoid pressure (unadjusted odds ratio, 1.64; 95% CI, 1.09-2.47; p = 0.018). On multivariable analysis, cricoid pressure was not associated with the occurrence of regurgitation after adjusting for patient, practice, and known regurgitation risk factors (adjusted odds ratio, 1.57; 95% CI, 0.99-2.47; p = 0.054). A sensitivity analysis in propensity score-matched cohorts showed cricoid pressure was associated with a higher regurgitation rate (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; p = 0.036). CONCLUSIONS: Cricoid pressure during induction and mask ventilation before tracheal intubation in the current ICU practice was not associated with a lower regurgitation rate after adjusting for previously reported confounders. Further studies are needed to determine whether cricoid pressure for specific indication with proper maneuver would be effective in reducing regurgitation events.
Assuntos
Cartilagem Cricoide/fisiopatologia , Estado Terminal/terapia , Intubação Intratraqueal/efeitos adversos , Refluxo Laringofaríngeo/epidemiologia , Canadá , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Intubação Intratraqueal/métodos , Japão , Refluxo Laringofaríngeo/etiologia , Refluxo Laringofaríngeo/prevenção & controle , Laringoscopia/efeitos adversos , Masculino , Nova Zelândia , Pressão , Pontuação de Propensão , Melhoria de Qualidade , Sistema de Registros , Estudos Retrospectivos , Singapura , Estados UnidosRESUMO
OBJECTIVES: External laryngeal manipulation is a commonly used maneuver to improve visualization of the glottis during tracheal intubation in children. However, the effectiveness to improve tracheal intubation attempt success rate in the nonanesthesia setting is not clear. The study objective was to evaluate the association between external laryngeal manipulation use and initial tracheal intubation attempt success in PICUs. DESIGN: A retrospective observational study using a multicenter emergency airway quality improvement registry. SETTING: Thirty-five PICUs within general and children's hospitals (29 in the United States, three in Canada, one in Japan, one in Singapore, and one in New Zealand). PATIENTS: Critically ill children (< 18 years) undergoing initial tracheal intubation with direct laryngoscopy in PICUs between July 1, 2010, and December 31, 2015. MEASUREMENTS AND MAIN RESULTS: Propensity score-matched analysis was performed to evaluate the association between external laryngeal manipulation and initial attempt success while adjusting for underlying differences in patient and clinical care factors: age, obesity, tracheal intubation indications, difficult airway features, provider training level, and neuromuscular blockade use. External laryngeal manipulation was defined as any external force to the neck during laryngoscopy. Of the 7,825 tracheal intubations, the initial tracheal intubation attempt was successful in 1,935/3,274 intubations (59%) with external laryngeal manipulation and 3,086/4,551 (68%) without external laryngeal manipulation (unadjusted odds ratio, 0.69; 95% CI, 0.62-0.75; p < 0.001). In propensity score-matched analysis, external laryngeal manipulation remained associated with lower initial tracheal intubation attempt success (adjusted odds ratio, 0.93; 95% CI, 0.90-0.95; p < 0.001). CONCLUSIONS: External laryngeal manipulation during direct laryngoscopy was associated with lower initial tracheal intubation attempt success in critically ill children, even after adjusting for underlying differences in patient factors and provider levels. The indiscriminate use of external laryngeal manipulation cannot be recommended.