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How to Intubate Pediatrics Patients More Safely

January 14, 2021

Written by Michael Wolf

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Implementing a pediatric intubation safety QI bundle is associated with sustained improvement in PICU intubations.

Why does this matter?
20% of all pediatric tracheal intubations are associated with adverse tracheal intubation-associated events (TIAEs), and 3% are associated with severe adverse TIAEs such as cardiac arrest. Checklists and bundles are popular, and for good reason! ABCDEF, pediatric readiness – simple protocols and standardized preparation – can supplement sound clinical judgment and skill, reduce errors, and improve outcomes. So why not try it with pediatric intubation?

Bundle of joy
This was a multicenter QI intervention study using the National Emergency Airway Registry for Children (NEAR4KIDS) to determine the effectiveness of a safety bundle to reduce adverse TIAEs. Data were collected from 19 ICUs from 2013-2015, in phases relating to timing of checklist implementation. NEAR4KIDS offers resources for centers looking to develop their own site-specific bundle, such as this one from CHOP, and encourages folks to assemble a multidisciplinary team to implement, study, and improve.

Severe TIAEs included cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension, laryngospasm, and pneumothorax/pneumomediastinum. Non-severe TIAEs included mainstem bronchial intubation, esophageal intubation with immediate recognition, emesis without aspiration, hypertension requiring treatment, epistaxis, dental/lip trauma, medication error, dysrhythmia, and pain/agitation delaying the procedure.

Adverse TIAEs decreased from 17.5% at baseline to 13.7% of intubations in the 2 years after centers demonstrated >80% bundle adherence. Adjusting for age, predicted mortality (PIM2), difficult airway history/features, indications for intubation, and site-level clustering, the odds of any TIAE decreased from baseline for all subsequent phases of the QI study. Most notably, the adjusted odds ratio of TIAE was 0.63 for the two years after >80% bundle compliance, compared to baseline.

Downsides: rates of multiple intubation attempts and hypoxemia with SpO2 < 90% did not decline after demonstration of bundle adherence. Also, sites that never demonstrated >80% adherence did not have a significant decline in TIAE frequency.

Sustained Improvement in Tracheal Intubation Safety Across a 15-Center Quality-Improvement Collaborative: An Interventional Study From the National Emergency Airway Registry for Children Investigators. Crit Care Med. 2020 Nov 11. doi: 10.1097/CCM.0000000000004725. Online ahead of print.

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