title: Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study.
abstract: OBJECTIVE
  Tracheal intubation in PICUs is often associated with adverse tracheal intubation-associated events. There is a paucity of data regarding medication selection for safe tracheal intubations in PICUs. Our primary objective was to evaluate the association of medication selection on specific tracheal intubation-associated events across PICUs.
  
  
  METHODS
  Prospective observational cohort study.
  
  
  METHODS
  Nineteen PICUs in North America.
  
  
  METHODS
  Critically ill children requiring tracheal intubation.
  
  
  METHODS
  None.
  
  
  RESULTS
  Using the National Emergency Airway Registry for Children, tracheal intubation quality improvement data were prospectively collected from July 2010 to March 2013. Patient, provider, and practice characteristics including medications and dosages were collected. Adverse tracheal intubation-associated events were defined a priori. A total of 3,366 primary tracheal intubations were reported. Adverse tracheal intubation-associated events occurred in 593 tracheal intubations (18%). Fentanyl and midazolam were the most commonly used induction medications (64% and 58%, respectively). Neuromuscular blockade was used in 92% of tracheal intubation with the majority using rocuronium (64%) followed by vecuronium (20%). Etomidate and succinylcholine were rarely used (1.6% and 0.7%, respectively). Vagolytics were administered in 37% of tracheal intubations (51% in infants; 28% in > 1 yr old; p < 0.001). Ketamine was used in 27% of tracheal intubations but more often for tracheal intubations in patients with unstable hemodynamics (39% vs 25%; p < 0.001). However, ketamine use was not associated with lower prevalence of new hypotension (ketamine 8% vs no ketamine 14%; p = 0.08).
  
  
  CONCLUSIONS
  In this large, pediatric multicenter registry, fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.
authors.affiliation: 1Department of Pediatrics, Pediatric Critical Care Medicine, Hasbro Children's Hospital, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI. 2Department of Pediatrics, Weill Cornell Medical College, New York, NY. 3Pediatric Critical Care Medicine, University of Louisville, Louisville, KY. 4Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Duke University Medical Center, Durham, NC. 5Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook University School of Medicine, Stony Brook, NY. 6Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. 7Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.
authors.forename: Keiko M
authors.initials: KM
authors.lastname: Tarquinio
authors.forename: Joy D
authors.initials: JD
authors.lastname: Howell
authors.forename: Vicki
authors.initials: V
authors.lastname: Montgomery
authors.forename: David A
authors.initials: DA
authors.lastname: Turner
authors.forename: Deyin D
authors.initials: DD
authors.lastname: Hsing
authors.forename: Margaret M
authors.initials: MM
authors.lastname: Parker
authors.forename: Calvin A
authors.initials: CA
authors.lastname: Brown
authors.forename: Ron M
authors.initials: RM
authors.lastname: Walls
authors.forename: Vinay M
authors.initials: VM
authors.lastname: Nadkarni
authors.forename: Akira
authors.initials: A
authors.lastname: Nishisaki
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016638:Critical Illness / Q000628:therapy*; D005260:Female; D005283:Fentanyl / Q000008:administration & dosage / Q000009:adverse effects*; D006439:Hemodynamics / Q000187:drug effects; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000009:adverse effects; D007022:Hypotension / Q000139:chemically induced; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000379:methods; D007649:Ketamine / Q000008:administration & dosage / Q000009:adverse effects*; D008297:Male; D008874:Midazolam / Q000008:administration & dosage / Q000009:adverse effects*; D019148:Neuromuscular Blockade / Q000009:adverse effects*; D011446:Prospective Studies
chemical_list: D006993:Hypnotics and Sedatives; D007649:Ketamine; D008874:Midazolam; D005283:Fentanyl