Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study. (Land)

da Silva PSL, et al. Does Tracheal Lidocaine Instillation Reduce Intracranial Pressure Changes After Tracheal Suctioning in Severe Head Trauma? A Prospective, Randomized Crossover Study. Pediatr Crit Care Med. 2019 Apr; 20(4):365-371.

OBJECTIVES: Tracheal suctioning is a routine procedure in mechanically ventilated children, however, in severe head-injured patients it can result in potential deleterious increase in intracranial pressure. We aimed to assess the effect of tracheal lidocaine administration on intracranial pressure during tracheal suctioning.

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Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults. (Patel)

Janz DR, et al. Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults. Crit Care Med. 2016 Nov;44(11):1980-1987.

OBJECTIVE: To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults.

DESIGN: A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows.

SETTING: Medical ICU in a tertiary, academic medical center.

PATIENTS: Critically ill patients 18 years old or older.

INTERVENTIONS: Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS: Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator’s previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy.

CONCLUSIONS: In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. (Colman)

Mahle WT, et al. Utilizing a Collaborative Learning Model to Promote Early Extubation Following Infant Heart Surgery. Pediatr Crit Care Med. 2016 Aug 10. [Epub ahead of print]

OBJECTIVE: To determine whether a collaborative learning strategy-derived clinical practice guideline can reduce the duration of endotracheal intubation following infant heart surgery.

DESIGN: Prospective and retrospective data collected from the Pediatric Heart Network in the 12 months pre- and post-clinical practice guideline implementation at the four sites participating in the collaborative (active sites) compared with data from five Pediatric Heart Network centers not participating in collaborative learning (control sites).

SETTING: Ten children’s hospitals.

PATIENTS: Data were collected for infants following two-index operations: 1) repair of isolated coarctation of the aorta (birth to 365 d) and 2) repair of tetralogy of Fallot (29-365 d). There were 240 subjects eligible for the clinical practice guideline at active sites and 259 subjects at control sites.

INTERVENTIONS: Development and application of early extubation clinical practice guideline.

MEASUREMENTS AND MAIN RESULTS: After clinical practice guideline implementation, the rate of early extubation at active sites increased significantly from 11.7% to 66.9% (p < 0.001) with no increase in reintubation rate. The median duration of postoperative intubation among active sites decreased from 21.2 to 4.5 hours (p < 0.001). No statistically significant change in early extubation rates was found in the control sites 11.7% to 13.7% (p = 0.63). At active sites, clinical practice guideline implementation had no statistically significant impact on median ICU length of stay (71.9 hr pre- vs 69.2 hr postimplementation; p = 0.29) for the entire cohort. There was a trend toward shorter ICU length of stay in the tetralogy of Fallot subgroup (71.6 hr pre- vs 54.2 hr postimplementation, p = 0.068).

CONCLUSIONS: A collaborative learning strategy designed clinical practice guideline significantly increased the rate of early extubation with no change in the rate of reintubation. The early extubation clinical practice guideline did not significantly change postoperative ICU length of stay.

Cardiac Arrests Associated With Tracheal Intubations in PICUs: A Multicenter Cohort Study. (Emrath)

Shiima Y, et al. Cardiac Arrests Associated With Tracheal Intubations in PICUs: A Multicenter Cohort Study. Crit Care Med. 2016 Apr 11. [Epub ahead of print]

OBJECTIVES: To determine the incidence and epidemiologic characteristics of cardiac arrests among tracheal intubations in PICUs.

DESIGN: Retrospective cohort study of prospectively collected data.

SETTING: Twenty-five diverse PICUs.

PATIENTS: Critically ill children requiring tracheal intubation in PICUs.

INTERVENTIONS: Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubations in 25 PICUs from July 2010 to March 2014 using National Emergency Airway Registry for Children registry.

MEASUREMENTS AND MAIN RESULTS: Tracheal intubation-associated cardiac arrest was defined as chest compressions more than 1 minute occurring during tracheal intubation or within 20 minutes after tracheal intubation. A total of 5,232 pediatric tracheal intubations were evaluated. Tracheal intubation-associated cardiac arrest was reported in 87 (1.7%). Patient factors (demographics and indications for tracheal intubation), provider factors (discipline and training level), and practice factors (tracheal intubation method and use of neuromuscular blockade) were recorded. Hemodynamic instability and oxygenation failure as tracheal intubation indications were associated with cardiac arrests (adjusted odds ratio, 6.3; 95% CI, 3.9-10.3; and adjusted odds ratio, 4.3; 95% CI, 2.6-6.9, respectively). History of difficult airway and cardiac disease were also associated with cardiac arrests (adjusted odds ratio, 2.1; 95% CI, 1.2-3.5; and adjusted odds ratio, 2.1; 95% CI, 1.2-3.9, respectively). Provider and practice factors were not associated with cardiac arrests, and provider factors did not modify the effect of patient factors on cardiac arrests.

CONCLUSIONS: Tracheal intubation-associated cardiac arrests occurred during 1.7% of PICU tracheal intubations. Tracheal intubation-associated cardiac arrests were much more common with tracheal intubations when the child had acute hemodynamic instability or oxygen failure and when the child had a history of difficult airway or cardiac disease.