title: Relationship Between Adverse Tracheal Intubation Associated Events and PICU Outcomes.
abstract: OBJECTIVE
  Tracheal intubation in PICUs is a common procedure often associated with adverse events. The aim of this study is to evaluate the association between immediate events such as tracheal intubation associated events or desaturation and ICU outcomes: length of stay, duration of mechanical ventilation, and mortality.
  
  
  METHODS
  Prospective cohort study with 35 PICUs using a multicenter tracheal intubation quality improvement database (National Emergency Airway Registry for Children: NEAR4KIDS) from January 2013 to June 2015. Desaturation defined as Spo2 less than 80%.
  
  
  METHODS
  PICUs participating in NEAR4KIDS.
  
  
  METHODS
  All patients less than18 years of age undergoing primary tracheal intubations with ICU outcome data were analyzed.
  
  
  RESULTS
  Five thousand five hundred four tracheal intubation encounters with median 108 (interquartile range, 58-229) tracheal intubations per site. At least one tracheal intubation associated event was reported in 892 (16%), with 364 (6.6%) severe tracheal intubation associated events. Infants had a higher frequency of tracheal intubation associated event or desaturation than older patients (48% infants vs 34% for 1-7 yr and 18% for 8-17 yr). In univariate analysis, the occurrence of tracheal intubation associated event or desaturation was associated with a longer mechanical ventilation (5 vs 3 d; p < 0.001) and longer PICU stay (14 vs 11 d; p < 0.001) but not with PICU mortality. The occurrence of severe tracheal intubation associated events was associated with longer mechanical ventilation (5 vs 4 d; p < 0.003), longer PICU stay (15 vs 12 d; p < 0.035), and PICU mortality (19.9% vs 9.6%; p < 0.0001). In multivariable analyses, the occurrence of tracheal intubation associated event or desaturation was significantly associated with longer mechanical ventilation (+12%; 95% CI, 4-21%; p = 0.004), and severe tracheal intubation associated events were independently associated with increased PICU mortality (OR = 1.80; 95% CI, 1.24-2.60; p = 0.002), after adjusted for patient confounders.
  
  
  CONCLUSIONS
  Adverse tracheal intubation associated events and desaturations are common and associated with longer mechanical ventilation in critically ill children. Severe tracheal intubation associated events are associated with higher ICU mortality. Potential interventions to decrease tracheal intubation associated events and oxygen desaturation, such as tracheal intubation checklist, use of apneic oxygenation, and video laryngoscopy, may need to be considered to improve ICU outcomes.
authors.affiliation: 1Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook Children's Hospital, Stony Brook, NY. 2Department of Pediatrics, Pediatric Intensive Care Unit, Starship Children's Hospital, Auckland, New Zealand. 3Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. 4Department of Pediatrics, Columbia University/New York Presbyterian Hospital, New York, NY. 5Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, PA. 6Division of Pediatric Critical Care Medicine, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Providence, RI. 7Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA. 8Department of Pediatric Critical Care Medicine, The Children's Hospital at Montefiore, Bronx, NY. 9Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ. 10Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore. 11Division of Pediatric Critical Care, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KY. 12Department of Child Health University of Arizona College of Medicine, Department of Critical Care Phoenix Children's Hospital, Phoenix, AZ. 13Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA. 14Division of Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC. 15Pediatric Critical Care Medicine, The University of Virginia Children's Hospital, Charlottesville, VA. 16Division of Pediatric Critical Care, Children's Hospital at Dartmouth, Dartmouth Hitchcock Medical Center, Lebanon, NH. 17Pediatric Critical Care Medicine, Penn State Hershey Children's Hospital, Hershey, PA. 18Pediatric Critical Care Medicine, Nicklaus Children's Hospital, Miami Children's Health System, Miami, FL. 19Critical Care Medicine, Department of Pediatrics, Yale Pediatric Critical Care Medicine, Yale University School of Medicine, New Haven, CT. 20Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Louisville, Louisville, KY. 21Pediatric Critical Care Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA. 22Section of Pediatric Critical Care, Department of Pediatrics, University of Arkansas College of Medicine, Little Rock, AR. 23Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital Westchester Medical Center, Valhalla, NY. 24Pediatric Critical Care Medicine, Medical City Children's Hospital, Dallas, TX. 25Department of Pediatrics, Sainte-Justine University Hospital Center, Montreal, QC, Canada. 26Department of Emergency Medicine, Tokyo Metropolitan Children's Medical Centre, Tokyo, Japan. 27Department of Critical Care Medicine, Children's Hospital of Pittsburgh at University of Pittsburgh Medical Center, Pittsburgh, PA. 28Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Scottish Rite, Atlanta, GA. 29Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR. 30Division of Critical Care, Nationwide Children's Hospital, Columbus, OH. 31Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Richmond at VCU, Richmond, VA. 32Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada. 33Division of Critical Care, Department of Pediatrics, Women & Children's Hospital of Buffalo, Buffalo, NY. 34Division of Pediatric Cardiac Intensive Care, Department of Pediatric Critical Care Medicine, Duke Children's Hospital & Health Center, Durham, NC.
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mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D016638:Critical Illness; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric / Q000706:statistics & numerical data*; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000401:mortality; D007902:Length of Stay / Q000706:statistics & numerical data*; D008297:Male; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D058996:Quality Improvement; D012121:Respiration, Artificial / Q000706:statistics & numerical data*; D012189:Retrospective Studies