Adverse Tracheal Intubation-Associated Events in Pediatric Patients at Nonspecialist Centers: A Multicenter Prospective Observational Study.

OBJECTIVES: In tertiary care PICUs, adverse tracheal intubation-associated events occur frequently (20%; severe tracheal intubation-associated events in 3-6.5%). However, pediatric patients often present to nonspecialist centers and require intubation by local teams. The rate of tracheal intubation-associated events is not well studied in this setting. We hypothesized that the rate of tracheal intubation-associated events would be higher in nonspecialist centers. DESIGN: Prospective observational study. SETTING: We conducted a multicenter study covering 47 local hospitals in the North Thames and East Anglia region of the United Kingdom. PATIENTS: All intubated children transported by the Children's Acute Transport Service from June 2016 to May 2018. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data were available in 1,051 of 1,237 eligible patients (85%). The overall rate of tracheal intubation-associated events was 22.7%, with severe tracheal intubation-associated events occurring in 13.8%. Younger, small-for-age patients and those with difficult airways had a higher rate of complications. Children with comorbidities and difficult airways were found to have increased severe tracheal intubation-associated events. The most common tracheal intubation-associated events were endobronchial intubation (6.2%), hypotension (5.4%), and bradycardia (4.2%). In multivariate analysis, independent predictors of tracheal intubation-associated events were number of intubation attempts (odds ratio for > 4 attempts compared with a single attempt 19.1; 95% CI, 5.9-61.4) and the specialty of the intubator (emergency medicine compared with anesthesiologists odds ratio 6.9; 95% CI, 1.1-41.4). CONCLUSIONS: Tracheal intubation-associated events are common in critically ill pediatric patients who present to nonspecialist centers. The rate of severe tracheal intubation-associated events is much higher in these centers as compared with the PICU setting. There should be a greater focus on improving the safety of intubations occurring in nonspecialist centers.

Shock Index Values and Trends in Pediatric Sepsis: Predictors or Therapeutic Targets? A Retrospective Observational Study.

BACKGROUND: Shock index (SI) (heart rate [HR]/systolic blood pressure [SBP]) has been used to predict outcome in both adult and pediatric sepsis within the intensive care unit (ICU). We aimed to evaluate the utility of SI before pediatric ICU (PICU) admission. PATIENTS AND METHODS: We conducted a retrospective observational study of children referred to a pediatric intensive care transport service (PICTS) between 2005 and 2011. The predictive value of SI, HR, and blood pressure at three prespecified time points (at referral to PICTS, at PICTS arrival at the referring hospital, and at PICU admission) and changes in SI between the time points were evaluated. Death within the first 48 h of ICU admission (early death) was the primary outcome variable. RESULTS: Over the 7-year period, 633 children with sepsis were referred to the PICTS. Thirty-nine children died before transport to a PICU, whereas 474 were transported alive. Adjusting for age, time points, and time duration in a multilevel regression analysis, SI was significantly higher in those who died early. There was a significant improvement in SI with the transport team in survivors but not in nonsurvivors. However, the predictive value of a change in SI for mortality was no better than either a change in HR or blood pressure. CONCLUSIONS: The absolute or change in SI does not predict early death any more than HR and SBP individually in children with sepsis.

Timing of death in children referred for intensive care with severe sepsis: implications for interventional studies.

OBJECTIVE: Early deaths in pediatric sepsis may limit the impact of therapies that can only be provided on PICUs. By introducing selection and survivorship biases, these very early deaths may also undermine the results of trials that employ standard consent procedures. We hypothesized that: 1) the majority of deaths in children with severe sepsis occur very early, within 24 hours of referral to PICU; and 2) a significant proportion of deaths occur before PICU admission. DESIGN, SETTING, AND PATIENTS: We studied consecutive referrals of newborns through to 16 years of age, between 2005 and 2011 to the Children's Acute Transport Service, the North Thames regional pediatric intensive care transport service, with a working diagnosis of "sepsis," "severe sepsis," "meningococcal sepsis," or "septic shock." INTERVENTIONS: The primary outcome measure was the proportion of deaths within 24 hours of referral. Survival distributions of previously healthy children were compared with those with significant comorbidities. MEASUREMENTS AND MAIN RESULTS: Thirteen thousand four hundred and nine referrals were made to Children's Acute Transport Service, of whom 703 (5%) met inclusion criteria. Data on survival to 1 year were available in 627 of 703 patients (89%). One hundred thirty children (130/627; 21%; 95% CI, 18-24%) died in the first year. A higher proportion of children with comorbidity cases (46/85, 54%, 44-64) died compared with previously healthy cases (84/542; 16%; 13-19; p < 0.0005, Fisher exact test). Seventy-one deaths occurred within 24 hours of PICU referral (71/130, 55%, 46-63). The timing of death differed with comorbidity. Similar proportions of children survived to 24 hours (previously healthy children 90% vs children with comorbidity 83%, p = 0.06). However, deaths after 24 hours were infrequent among previously healthy cases (28/84 deaths, 33%, 24-44%) compared with children with comorbidity cases (31/46 deaths, 66%, 53-79%) (p < 0.001, Fisher exact test). CONCLUSIONS: This majority of deaths among children referred for pediatric intensive care with for severe sepsis occur within 24 hours. This has important implications for future clinical trials and quality improvement initiatives aimed at improving sepsis outcomes.

Emergency management of children with acute severe asthma requiring transfer to intensive care.

PURPOSE: Children presenting to emergency departments (ED) with acute severe asthma unresponsive to initial medical therapy may require endotracheal intubation and mechanical ventilation. There is little data on complications during the acute management of children with life-threatening asthma, particularly at hospitals where specialist paediatric staff are lacking. It was hypothesised that a better understanding of complications, particularly associated with intubation and mechanical ventilation, would improve acute management in ED, aid quality improvement initiatives at district general hospitals (DGH) and form the basis for educational interventions from regional paediatric critical care units. METHODS: A retrospective case note review was performed for all children referred to a regional intensive care retrieval service with status asthmaticus over a 2-year period. Initial treatment, patient-related factors, indication for endotracheal intubation and the type and occurrence of adverse events during acute management at the DGH were studied. Bivariate and multivariate analyses were undertaken to identify factors associated with the occurrence of complications. RESULTS: 51 (85%) of the 60 children transferred to a paediatric intensive care unit for acute severe asthma required intubation. 36 (70.5%) experienced one or more complications during intubation and in the early phase of mechanical ventilation. The most common complications were hypotension (requiring fluid resuscitation and/or inotropic support) and severe bronchospasm with acute hypercarbia. The indication for intubation significantly affected the chances of a complication occurring during stabilisation. CONCLUSIONS: There is considerable morbidity in asthmatic children who are referred to paediatric intensive care. The majority of complications may be anticipated and prevented resulting in improved management at DGH.

Effect of patient- and team-related factors on stabilization time during pediatric intensive care transport.

OBJECTIVES: To examine the effects of patient- and transport-related factors on the time spent at the referring hospital by an intensive care retrieval team to stabilize critically ill children and to study the relationship between stabilization time and patient outcome. DESIGN: : Analysis of prospectively collected data during pediatric intensive care transport. SETTING: A dedicated regional pediatric intensive care retrieval service performing interhospital transports in England. PATIENTS: Critically ill children transported to intensive care units over a 2-yr period between April 1, 2006 and March 31, 2008. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Factors related to the patient (age group, diagnostic category, and severity of illness) and transport (time of referral, team response time, and number of major and minor interventions performed) were analyzed for their effect on stabilization time in univariate and multivariate analyses. The relationship between stabilization time and patient outcome in the first 24 hrs post intensive care unit admission was also studied. Patient acuity was high in the transported population (84% invasively ventilated; 28% on vasoactive agents). Predicted mortality risk (Pediatric Index of Mortality 2 score), diagnostic category, team response time, and number of major interventions performed had an independent effect on stabilization time, whereas the length of stabilization itself did not influence early mortality on the intensive care unit. Each minor intervention prolonged the stabilization time by an average of 10 mins. CONCLUSIONS: Stabilization time during intensive care transport is influenced by a number of patient- and transport-related factors, and cannot be used in isolation as an indicator of team efficiency. Time spent undertaking intensive care interventions early in the course of patient illness at the referring hospital does not worsen patient outcome, suggesting that the "scoop and run" model can be safely abandoned in interhospital transport.

Inhaled nitric oxide in neonatal and paediatric transport.

Since the first reports of the use of inhaled nitric oxide in the early 1990s its applications have been refined to a number of specific conditions. Pre-term and term neonates benefit significantly in the improvement of oxygenation in conditions such as hypoxic respiratory failure and persistent pulmonary hypertension of the neonate and the reduction in referral rates to extra corporeal membrane oxygenation. Many neonatal units still do not have the ability to administer inhaled nitric oxide though an increasing number of neonatal units have acquired the capability to deliver inhaled nitric oxide in recent years with commercially available delivering devices. In either case if the neonate needs transfer for further management or extra corporeal membrane oxygenation the journey can be improved if inhaled nitric oxide is introduced during transport or could deteriorate if inhaled nitric oxide was discontinued during transport. Delivery of inhaled nitric oxide during transport can be technically challenging and the consequences of increased or interrupted delivery can be dangerous. The different modes of transport either by road or air can influence the method of delivery. We describe our method of delivering inhaled nitric oxide during the retrievals we undertake and how this changes depending upon the type of journey performed. We also suggest guidelines for its use during transport and outline the precautions we take to ensure safety of patient and carers during transport.

Hyperventilation in severe diabetic ketoacidosis.

OBJECTIVE: To explore whether the carbon dioxide-bicarbonate (P(CO(2))-HCO(3)) buffering system in blood and cerebrospinal fluid (CSF) in diabetic ketoacidosis should influence the approach to ventilation in patients at risk of cerebral edema. DATA SOURCE: Medline search, manual search of references in articles found in Medline search, and use of historical literature from 1933 to 1967. DESIGN: A clinical vignette is used--a child with severe diabetic ketoacidosis who presented with profound hypocapnia and then deteriorated--as a basis for discussion of integrative metabolic and vascular physiology. STUDY SELECTION: Studies included reports in diabetic ketoacidosis where arterial and CSF acid-base data have been presented. Studies where simultaneous acid-base, ventilation, respiratory quotient, and cerebral blood flow data are available. DATA EXTRACTION AND SYNTHESIS: We revisit a hypothesis and, by reassessing data, put forward an argument based on the significance of low [HCO(3)](CSF) and rising Pa(CO(2))- hyperventilation in diabetic ketoacidosis and the limit in biology of survival; repair of severe diabetic ketoacidosis and Pa(CO(2))-and mechanical ventilation. CONCLUSION: The review highlights a potential problem with mechanical ventilation in severe diabetic ketoacidosis and suggests that the P(CO(2))--HCO(3) hypothesis is consistent with data on cerebral edema in diabetic ketoacidosis. It also indicates that the recommendation to avoid induced hyperventilation early in the course of intensive care may be counter to the logic of adaptive physiology.