ETT During Pediatric Arrest May Harm

January 11, 2017

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Short Attention Span Summary

Get them back – then intubate them.
This was a retrospective review of a large pediatric in-hospital arrest registry (2294 patients) that found intubation during resuscitation was associated with worse outcomes.  68% were intubated during arrest.  Survival to discharge was 36% in those intubated vs 41% in those who were not. This was statistically adjusted and was still significant.  They also ran several sensitivity analyses which all confirmed the same, so I think these results are accurate. While there could be confounders, this study calls into question an emphasis on early intubation during pediatric arrest.  The editorial below entitled Confounding by Indication is helpful.  It points out that kids with more severe disease may have been more likely to receive aggressive airway management than others, potentially confounding the results.  Bottom line is that it is usually easy to bag pediatric patients, and it is harder to intubate them, especially during CPR.  So it is probably best to focus on high quality CPR and intubate later.

Spoon Feed
Intubation during pediatric arrest did not appear to benefit and may be harmful.

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Abstract

JAMA. 2016 Nov 1;316(17):1786-1797. doi: 10.1001/jama.2016.14486.

Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival.

Andersen LW1, Raymond TT2, Berg RA3, Nadkarni VM3, Grossestreuer AV4, Kurth T5, Donnino MW6; American Heart Association’s Get With The Guidelines–Resuscitation Investigators.

Author information:

1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts2Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark3Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.

2Division of Cardiac Critical Care, Department of Pediatrics, Medical City Children’s Hospital, Dallas, Texas.

3Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania6Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia7Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia.

4Department of Emergency Medicine, University of Pennsylvania, Philadelphia9Now with the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

5Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany.

6Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts11Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Comment in

• Intubation During Pediatric CPR: Early, Late, or Not at All? [JAMA. 2016]
• Confounding by Indication in Clinical Research. [JAMA. 2016]

Abstract

Importance:

Tracheal intubation is common during pediatric in-hospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown.

Objective:

To determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes.

Design, Setting, and Participants:

Observational study of data from United States hospitals in the Get With The Guidelines-Resuscitation registry. Pediatric patients (<18 years) with index in-hospital cardiac arrest between January 2000 and December 2014 were included. Patients who were receiving assisted ventilation, had an invasive airway in place, or both at the time chest compressions were initiated were excluded.

Exposures:

Tracheal intubation during cardiac arrest .

Main Outcomes and Measures:

The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and neurologic outcome. A favorable neurologic outcome was defined as a score of 1 to 2 on the pediatric cerebral performance category score. Patients being intubated at any given minute were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

Results:

The study included 2294 patients; 1308 (57%) were male, and all age groups were represented (median age, 7 months [25th-75th percentiles, 21 days, 4 years]). Of the 2294 included patients, 1555 (68%) were intubated during the cardiac arrest. In the propensity score-matched cohort (n = 2270), survival was lower in those intubated compared with those not intubated (411/1135 [36%] vs 460/1135 [41%]; risk ratio [RR], 0.89 [95% CI, 0.81-0.99]; P = .03). There was no significant difference in return of spontaneous circulation (770/1135 [68%] vs 771/1135 [68%]; RR, 1.00 [95% CI, 0.95-1.06]; P = .96) or favorable neurologic outcome (185/987 [19%] vs 211/983 [21%]; RR, 0.87 [95% CI, 0.75-1.02]; P = .08) between those intubated and not intubated. The association between intubation and decreased survival was observed in the majority of the sensitivity and subgroup analyses, including when accounting for missing data and in a subgroup of patients with a pulse at the beginning of the event.

Conclusions and Relevance:

Among pediatric patients with in-hospital cardiac arrest, tracheal intubation during cardiac arrest compared with no intubation was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding, these findings do not support the current emphasis on early tracheal intubation for pediatric in-hospital cardiac arrest.

PMID: 27701623 [PubMed – in process]