Emergency intubation of children outside of the operating room.

Intubation of children outside of the operating room is performed infrequently and is often associated with life-threatening adverse events. This review aims to clarify the contributors to adverse events encountered during intubations outside of the operating room and provide preventative strategies. The primary contributors to adverse events during non-operating room intubations are physiologically and situationally difficult airways; anatomically difficult airways are rare. Systems-based changes, including a shared mental model, standardization in equipment and its location, checklist use, physiological resuscitation prior to resuscitation, dose titration of induction agent, multi-disciplinary team training in the technical and nontechnical aspects of non-operating room intubation, debrief post-real and simulated events, and regular audit of performance all reduce life-threatening intubation-related adverse events in children. Intubation of children outside of the operating room may be performed safely through engagement of all critical care specialties, shared learning, and focus on patient-centered care delivery.

Implementation of NAP4 emergency airway management recommendations in a quaternary-level pediatric hospital.

Emergency airway management, particularly outside of the operating room, is associated with a high incidence of life-threatening adverse events. Based on the recommendations of the 4th National Audit Project, we aimed to develop hospital-wide systems changes to improve the safety of emergency airway management. We describe a framework for governance in the form of a hospital airway special interest group. We describe the development and implementation of the following systems changes: 1. A local intubation algorithm modified from the Difficult Airway Society's plan A-B-C-D approach, including clear pathways for airway escalation, and emphasizing the concepts of resuscitation prior to intubation, planning for failure, and avoidance of fixation error. 2. Simplified and standardized airway equipment located in identical airway carts in all critical care areas. 3. A preintubation checklist and equipment template to standardize preparation for airway management. 4. Availability of continuous waveform endtidal capnography in all critical care areas for confirmation of correct endotracheal tube placement. 5. Multidisciplinary team training to address the technical and nontechnical aspects of nonoperating room intubation. In addition, we describe methodology for ongoing monitoring of performance through a quality assurance framework. In conclusion, changes in the process of emergency airway management at a hospital level are feasible through collaboration. Their impact on patient-based outcomes requires further study.

Endotracheal intubation in the pediatric emergency department.

BACKGROUND AND OBJECTIVES: Prospective safety data on emergency department (ED) intubation in children are limited. We aimed to describe the practice and adverse events associated with endotracheal intubation in a large urban pediatric ED. METHODS: Prospective observational study at a tertiary pediatric ED with an annual census of 82,000. The primary outcome measure was the adverse event rate. Secondary outcome measures were incidence of difficult laryngoscopy and first pass success rate without desaturation or hypotension. RESULTS: Over a 12-month period in 2013, there were 71 intubations in 66 patients (9/10,000 ED visits). Median age was 3 years, with 25% in infants <1 year of age. Indications were as follows: trauma (21%) and medical conditions (79%); most frequently status epileptics (31%). Forty-four percent had cardiovascular compromise, 87% had respiratory compromise, and 70% had a GCS <9 prior to intubation. Adverse events occurred in 39%, the most common being hypotension (21%) and desaturation (14%). One anticipated and one unanticipated difficult laryngoscopy were encountered (both Cormack and Lehane grade 3). Overall first pass success rate was 78%, although first pass success without desaturation or hypotension was only 49%. Seven percent required more than two attempts for successful intubation. CONCLUSION: Intubation of children in the ED is a low-frequency, high-risk procedure. The incidence of adverse events, particularly desaturation and hypotension, is high. The incidence of difficult laryngoscopy is low. First pass success rate without desaturation or hypotension is low. Strategies to avoid desaturation and hypotension in the peri-intubation setting should be prioritized.

Airway emergencies presenting to the paediatric emergency department requiring advanced management techniques.

BACKGROUND: Airway emergencies presenting to the emergency department (ED) are usually managed with conventional equipment and techniques. The patient group managed urgently in the operating room (OR) has not been described. AIMS: This study aims to describe a case series of children presenting to the ED with airway emergencies managed urgently in the OR, particularly the anaesthetic equipment and techniques used and airway findings. METHODS: A retrospective cohort study undertaken at The Royal Children's Hospital, Melbourne, Australia. All patients presenting to the ED between 1 January 2012 and 30 July 2015 (42 months) with an airway emergency who were subsequently managed in the OR were included. Patient characteristics, anaesthetic equipment and technique and airway findings were recorded. RESULTS: Twenty-two airway emergencies in 21 patients were included over the study period, on average one every 2 months. Median age was 18 months and 43% were male. Inhalational induction was used in 77.3%, combined inhalational and intravenous induction in 9.1%, and intravenous induction alone in 13.6%. The most commonly used inhalational induction agent was sevoflurane, and the most commonly used intravenous induction agents were ketamine and propofol. Ten airway emergencies did not require intubation, seven for removal of inhaled foreign body, two with progressive tracheal stenosis requiring emergent dilatation and one examination under anaesthesia to rule out inhaled foreign body. Of the 12 airway emergencies that required immediate intubation, direct laryngoscopy was used in 9 and fibre-optic intubating bronchoscopy in 3. For intubations performed by direct laryngoscopy, one was difficult (Cormack and Lehane grade 3). First pass success was 83.3%. Adverse events occurred in 3/22 (13.6%) cases. CONCLUSION: Advanced airway techniques, including inhalational induction and intubation via fibre-optic intubating bronchoscope, are rarely but predictably required in the management of patients presenting to the ED. Institutions caring for children should prepare in advance where such patients should be managed, by whom, and provide equipment and training for their care.