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Preventing Death by Intubation in Kids

August 27, 2020

Written by Clay Smith

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Hypoxia (or inability to measure pulse oximetry), was the most powerful predictor of pediatric peri-intubation cardiac arrest (PICA). This plus age under 1 would have been moderately accurate for predicting PICA.

Why does this matter?
We know in adults hypotension, hypoxemia, absence of preoxygenation, obesity, and age over 75 were associated with PICA. What about children?

Optimize everything prior to intubating hypoxic babies…
This was a single center case-control study over a nine-year period with 543 intubations. There were 21 cases of pediatric PICA in the PED, most of whom had ROSC and over half of whom survived to discharge. They matched them with 4 randomly selected controls per case (84 patients) who were intubated in the PED and did not arrest. Predictors of PICA on univariate analysis were: age < 1 year, delayed capillary refill, systolic or diastolic hypotension, hypoxia, >1 intubation attempt, no use of induction agent or paralytic, and underlying pulmonary disease. The authors point out that for the strongest associated variables, there were several problems during a critical resuscitation: BP measurements are often missing (many lacking in the dataset); capillary refill is highly subjective and often abnormal in patients in extremis; lack of drugs might simply indicate a peri-arrest state and be confounding by indication. The strongest association with PICA was hypoxia or inability to measure pulse oximetry (OR 66.6, 95%CI 12.7–349.1). When looking for combinations to make an accurate predictor, the best was hypoxia and age <1 year, with an area under the ROC curve of 0.87. A caution – we cannot consider this a “prediction rule.” This study would be the first step, namely finding the variables to include in a rule. That said, we can learn something with practical clinical importance, although somewhat intuitive. Younger babies that are hypoxic are the most likely to arrest. Optimizing oxygenation (and perfusion) prior to intubation may save a life.

Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department. Pediatr Emerg Care. 2020 Jun 22. doi: 10.1097/PEC.0000000000002171. [Epub ahead of print]

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