Association between the presence of an advanced airway and ventilation rate during pediatric CPR: A report from the Videography in Pediatric Resuscitation (VIPER) collaborative.

OBJECTIVE: To determine the association between presence of an advanced airway during pediatric cardiopulmonary resuscitation (CPR) and ventilation rates. METHODS: Prospective observational study, January 2017 to June 2020. Patients ≤18 years receiving CC for ≥2 minutes were enrolled. Ventilation rate and type of airway (advanced airway (AA), either endotracheal tube (ETT) or supraglottic airway (SGA); or natural airway (NA)) were collected from video review and analyzed in 'CPR segments' (periods of CPR by individual providers). Ventilation rate (breaths per minute, bpm) was calculated for each segment; hyperventilation was defined as >12 bpm according to 2015 American Heart Association guidelines. Univariate analysis between airway type was done by χ2 testing. Multivariate regression was used to determine the association between the presence of AA with hyperventilation while controlling for within-patient covariance. RESULTS: 779 CPR segments from 94 CPR event were analyzed. The mean ventilation rate per CPR segment across all events was 22 bpm (±16 bpm)). Mean ventilation rates were higher with AA, either ETT (24 ± 17 bpm) or SGA (34 ± 19 bpm), than with NA (17 ± 14, p < 0.001). Hyperventilation occurred more often with AA in place (ETT: 68%; SGA: 96%; NA: 43%; p < 0.001). The presence of AA was independently associated with hyperventilation (AOR 9.3, 95% CI 4.3-20.1). CONCLUSIONS: During pediatric CPR, hyperventilation occurs more often with an AA in place than during CPR with NA. Future research should focus on respiratory physiology during pediatric CPR to determine optimal ventilation rate(s) during pediatric cardiac arrest.

High-risk criteria for the physiologically difficult paediatric airway: A multicenter, observational study to generate validity evidence.

BACKGROUND: Single-center studies have identified risk factors for peri-intubation cardiac arrest in the emergency department (ED). The study objective was to generate validity evidence from a more diverse, multicenter cohort of patients. METHODS: We completed a retrospective cohort study of 1200 paediatric patients who underwent tracheal intubation in eight academic paediatric EDs (150 per ED). The exposure variables were 6 previously studied high-risk criteria for peri-intubation arrest: (1) persistent hypoxemia despite supplemental oxygen, (2) persistent hypotension, (3) concern for cardiac dysfunction, (4) post-return of spontaneous circulation (ROSC), (5) severe metabolic acidosis (pH < 7.1), and (6) status asthmaticus. The primary outcome was peri-intubation cardiac arrest. Secondary outcomes included extracorporeal membrane oxygenation (ECMO) cannulation and in-hospital mortality. We compared all outcomes between patients that met one or more versus no high-risk criteria, using generalized linear mixed models. RESULTS: Of the 1,200 paediatric patients, 332 (27.7%) met at least one of 6 high-risk criteria. Of these, 29 (8.7%) suffered peri-intubation arrest compared to zero arrests in patients meeting none of the criteria. On adjusted analysis, meeting at least one high-risk criterion was associated with all 3 outcomes - peri-intubation arrest (AOR 75.7, 95% CI 9.7-592.6), ECMO (AOR 7.1, 95% CI 2.3-22.3) and mortality (AOR 3.4, 95% 1.9-6.2). Four of 6 criteria were independently associated with peri-intubation arrest: persistent hypoxemia despite supplemental oxygen, persistent hypotension, concern for cardiac dysfunction, and post-ROSC. CONCLUSIONS: In a multicenter study, we confirmed that meeting at least one high-risk criterion was associated with paediatric peri-intubation cardiac arrest and patient mortality.

Postintubation Sedation Practices Within Multiple Emergency Departments Across a Large Pediatric Health Care Organization.

OBJECTIVE: Children requiring rapid or standard sequence intubation are at risk of experiencing paralysis without adequate sedation when the duration of neuromuscular blockade exceeds the duration of sedation provided by the induction agent. The objective of this study was to evaluate the rate of appropriately timed postintubation sedation (PIS; defined as the administration of PIS before the clinical effects of the induction agent have dissipated) in patients requiring intubation across multiple emergency department/urgent care sites within a large pediatric health care organization. METHODS: This retrospective cohort study included patients admitted to 1 of 6 affiliated pediatric emergency department or urgent care sites who were intubated with an induction agent and neuromuscular blocker between January 2016 and December 2021. Patients were excluded if they were intubated in the setting of status epilepticus or cardiac arrest. Stepwise logistic regression identified factors associated with appropriately timed PIS. RESULTS: A total of 283 patients met the inclusion criteria (mean age, 8 ± 7.6 years; 56% male). Two hundred thirty-eight patients (83%) received some form of PIS (105 [37%] received appropriately timed PIS and 133 [47%] received delayed PIS), and 45 patients (16%) received no PIS. The median time to receive PIS following administration of the induction agent was 21 minutes (interquartile range, 11-40 minutes). Patients induced with fentanyl were the least likely to receive PIS, whereas patients induced with etomidate were the most likely. However, because of the short duration of etomidate, most patients induced with etomidate failed to receive PIS in a timely manner. CONCLUSIONS: Delayed PIS is common and may result in periods of ongoing paralysis without adequate sedation. Emergency department providers and pharmacists must recognize the brevity of some induction agents and provide more timely PIS.

The effect of hand position on chest compression quality during CPR in young children: Findings from the Videography in Pediatric Resuscitation (VIPER) collaborative.

OBJECTIVE: To determine the effect of hand position on chest compression (CC) quality during CPR in young children. METHODS: Prospective observational exploratory study. Patients < 8 years receiving CC for > 2 minutes were enrolled. Data was collected from video review and CC monitor device and analyzed in 'CC segments' (periods of CC by individual providers). Four techniques were compared: two thumbs (2 T), hands encircling the chest; two fingers (2F) on the sternum; one hand on sternum (1H); two hands on sternum (2H). Univariate analysis of CC rate and depth between hand positions was performed through nonparametric testing, stratified by age category. RESULTS: 47 patients received 824 minutes of CC. Among 270 CC segments in infants < 1 yo, 2 T was used in 27%; 2F 3%; 1H 18%; 2H 26%. Among 189 CC segments in children aged 1 to 8 yo, 1H was used in 26%; 2H 74%. Across all segments, median CC rate was 117 cpm (IQR 110-125). Median depth was 2.92 cm (IQR 2.44 - 4.04) in infants < 1 yo, 3.56 cm (IQR 2.92 - 4.14) in children 1 to 8 yo. 1H achieved greater depth than 2 T in infants (p < 0.01), and 2H achieved greater depth than 1H in children > 1 (p < 0.001). CONCLUSIONS: In infants, 1H resulted in greater CC depth than 2 T. In children 1 to 8 yo, 2H resulted in greater depth than 1H.. These data suggest that different hand position during CPR in young children from what is currently recommended may result in better CPR quality.

Video-Assisted Laryngoscopy for Pediatric Tracheal Intubation in the Emergency Department: A Multicenter Study of Clinical Outcomes.

STUDY OBJECTIVE: To explore the association between video-assisted laryngoscopy (use of a videolaryngoscope regardless of where laryngoscopists direct their gaze), first-attempt success, and adverse airway outcomes. METHODS: We conducted an observational study using data from 2 airway consortiums that perform prospective surveillance: the National Emergency Airway Registry for Children (NEAR4KIDS) and a pediatric emergency medicine airway education collaborative. Data collected included patient and procedural characteristics and procedural outcomes. We performed multivariable analyses of the association of video-assisted laryngoscopy with individual patient outcomes and evaluated the association between site-level video-assisted laryngoscopy use and tracheal intubation outcomes. RESULTS: The study cohort included 1,412 tracheal intubation encounters performed from January 2017 to March 2021 across 11 participating sites. Overall, the first-attempt success was 70.0%. Video-assisted laryngoscopy was associated with increased odds of first-attempt success (odds ratio [OR] 2.01; 95% confidence interval [CI], 1.48 to 2.73) and decreased odds of severe adverse airway outcomes (OR 0.70; 95% CI, 0.58 to 0.85) including decreased severe hypoxia (OR 0.69; 95% CI, 0.55 to 0.87). Sites varied substantially in the use of video-assisted laryngoscopy (range from 12.9% to 97.8%), and sites with high use of video-assisted laryngoscopy (> 80%) experienced increased first-attempt success even after adjusting for individual patient laryngoscope use (OR 2.30; 95% CI, 1.79 to 2.95). CONCLUSION: Video-assisted laryngoscopy is associated with increased first-attempt success and fewer adverse airway outcomes for patients intubated in the pediatric emergency department. There is wide variability in the use of video-assisted laryngoscopy, and the high use is associated with increased odds of first-attempt success.

See one, see one, teach one - Decisions on allocating intubation opportunities in pediatric emergency medicine.

Background: Decisions about who should perform tracheal intubation in academic settings must balance the needs of trainees to develop competency in pediatric intubation with patient safety. Airway protocols during the COVID-19 pandemic may have reduced opportunities for trainees, representing an opportunity to examine the impact of shifting laryngoscopy responsibilities away from trainees. Methods: This observational study combined data from 11 pediatric emergency departments in North America participating in either the National Emergency Airway Registry for Children (NEAR4KIDS) or a national pediatric emergency medicine airway education collaborative. Sites provided information on airway protocols, patient and procedural characteristics, and clinical outcomes. For the pre-pandemic (January 2017 to March 2020) and pandemic (March 2020 to March 2021) periods, we compared tracheal intubation opportunities by laryngoscopist level of training and specialty. We also compared first-attempt success and adverse airway outcomes between the two periods. Results: There were 1129 intubations performed pre-pandemic and 283 during the pandemic. Ten of 11 sites reported a COVID-19 airway protocol-8 specified which clinician performs tracheal intubation and 10 advocated for videolaryngoscopy. Both pediatric residents and pediatric emergency medicine fellows performed proportionally fewer tracheal intubation attempts during the pandemic: 1.1% of all first attempts versus 6.4% pre-pandemic for residents (p < 0.01) and 38.4% versus 47.2% pre-pandemic for fellows (p = 0.01). Pediatric emergency medicine fellows had greater decrease in monthly intubation opportunities for patients <1 year (incidence rate ratio = 0.35, 95% CI: 0.2, 0.57) than for older patients (incidence rate ratio = 0.79, 95% CI: 0.62, 0.99). Neither the rate of first-attempt success nor adverse airway outcomes differed between pre-pandemic and pandemic periods. Conclusions: The COVID-19 pandemic led to pediatric institutional changes in airway management protocols and resulted in decreased intubation opportunities for pediatric residents and pediatric emergency medicine fellows, without apparent change in clinical outcomes.

Videographic Assessment of Tracheal Intubation Technique in a Network of Pediatric Emergency Departments: A Report by the Videography in Pediatric Resuscitation (VIPER) Collaborative.

STUDY OBJECTIVE: We sought to describe the tracheal intubation technique across a network of children's hospitals and explore the association between intubation technical adjuncts and first-attempt success as well as between laryngoscopy duration and the incidence of hypoxemia. METHODS: We conducted a prospective observational study in 4 tertiary pediatric emergency departments of the Videography in Pediatric Resuscitation Collaborative. Children undergoing tracheal intubation captured on video were eligible for inclusion. Data on intubator background, patient characteristics, technical characteristics (eg, use of videolaryngoscopy and apneic oxygenation), and procedural outcomes were obtained through a video review. RESULTS: We obtained complete data on first attempts in 494 patients. The first-attempt success rate was 67%, the median laryngoscopy duration was 35 seconds (interquartile range 25 to 40), and hypoxemia occurred in 15% of the patients. Videolaryngoscopy was used for at least a part of the procedure in 48% of the attempts, and it had no association with success or the incidence of hypoxemia. Attempts in which videolaryngoscopy was used for the entire procedure (compared with direct laryngoscopy for the entire procedure) had a longer duration (the difference between the medians was 6 seconds; 95% confidence interval, 1 to 12 seconds). Intubation attempts longer than 45 seconds had a greater incidence of hypoxemia (29% versus 6%). Furthermore, apneic oxygenation was used in 8% of the first attempts. CONCLUSION: Among children undergoing tracheal intubation in a group of pediatric emergency departments, first-attempt success occurred in 67% of the patients. Videolaryngoscopy use was associated with longer laryngoscopy durations but was not associated with success or the incidence of hypoxemia.

Updated Approaches to Cardiac Electrical Stimulation and Pacing in Pediatrics.

Cardiac electrical stimulation is a rarely used but required skill for pediatric emergency physicians. Children who are in cardiac arrest or who demonstrate evidence of hypoperfusion because of cardiac reasons require rapid diagnosis and intervention to minimize patient morbidity and mortality. Both hospital- and community-based personnel must have sufficient access to, and knowledge of, appropriate equipment to provide potentially lifesaving defibrillation, cardioversion, or cardiac pacing. In this review, we will discuss the primary clinical indications for cardioelectrical stimulation in pediatric patients, including the use of automated external defibrillators, internal defibrillators, and pacemakers. We discuss the types of devices that are currently available, emergency management of internal defibrillation and pacemaker devices, and the role of advocacy in improving delivery of emergency cardiovascular care of pediatric patients in the community.

Breathing Easier: Decreasing Tracheal Intubation-associated Adverse Events in the Pediatric ED and Urgent Care.

Tracheal intubation is a high-risk procedure in the pediatric emergency department (PED) and pediatric urgent care (PUC) settings. We aimed to develop an airway safety intervention to decrease severe tracheal intubation-associated adverse events (TIAEs) by decreasing process variation. METHODS: After gathering baseline data on TIAE, an interdisciplinary team underwent a mini-Delphi process to identify key drivers for decreasing severe TIAE rates. We launched a 4-part airway safety bundle that included: (1) color-coded weight-based equipment chart, (2) visual schematic of airway equipment, (3) recommended medication dosing, and (4) safety checklist across a single, tertiary PED and 5 satellite community PUCs/PEDs. Multiple plan-do-study-act cycles were undertaken, and results were monitored using statistical process control charts. Charts were restaged when special cause variation was achieved. This study aimed to decrease the severe TIAE rate from a baseline of 23% in the tertiary site and 25% in the community sites to <15% within 12 months and to sustain these outcomes for 6 months. RESULTS: During the study period, we noted decreased rates of severe TIAE in both the PED and PUC setting during the intervention period, and we have sustained this improvement for more than 6 months in all sites with no associated change in balancing measures. CONCLUSIONS: Implementation of an airway safety bundle over a wide geographic area and among personnel with variable levels of training is possible and has the potential to decrease severe TIAE across multiple clinical settings.

Massive Gastrointestinal Bleed as Presentation for Previously Undiagnosed Coarctation of Aorta.

BACKGROUND: Coarctation of the aorta is a common congenital heart lesion with a known complication of collateral vessel formation if left untreated. OBJECTIVE: To alert pediatric emergency physicians of a rare and life-threatening presentation of previously undiagnosed congenital heart disease in the adolescent. CASE: We discuss the case of a 15-year-old boy who presented with hypertension and massive upper GI bleed due to aortoenteric fistula formation associated with undiagnosed coarctation of the aorta. There are no other reports of a similar presentation in the literature.

Fascia iliaca compartment nerve block versus systemic pain control for acute femur fractures in the pediatric emergency department.

OBJECTIVE: To compare management of acute femur fractures in children who received a fascia iliaca compartment nerve block (FICNB) to those who received systemic intravenously administered analgesics in the pediatric emergency department. The comparison evaluated frequency of use, effectiveness, and associated adverse event profiles. METHODS: Study population was derived from a retrospective chart review of pediatric patients sustaining acute femur fractures between 2005 and 2009. Cases (received FICNB) were compared with controls (only systemic analgesia) in terms of effectiveness and adverse event. Outcomes included total doses of systemic medications received and comparison of preintervention and postintervention pain scores. RESULTS: Two hundred fifty-nine charts were reviewed: 158 who received FICNB versus 101 who did not. The median dose of systemic medications was 1 dose lower in the FICNB group compared with the systemic medications group. This remained significant after controlling for age and preintervention pain scores (P = 0.02). Median postintervention pain scores in the FICNB group were 1.5 points lower than those in the systemic medications group. This remained significant while controlling for preintervention pain scores and age (P < 0.01). There was no difference in the total adverse events between the FICNB and the control group in either the unadjusted or adjusted analyses (P = 0.08). The FICNB group had 2 seizure episodes, one of which had associated subarachnoid hemorrhage. No patient in either group experienced bradycardia, arrhythmia, visual disturbance, abnormal hearing, mouth numbness, motor tremors, pain or bleeding at injection site, or prolonged nerve block. CONCLUSIONS: We report on the largest number of FICNBs administered in a pediatric emergency department for acute femur fractures. Effectiveness, as measured by pain scores and total doses of systemic analgesia, was improved in the FICNB group versus the control. There was no difference in adverse events between the groups.