Association of presence and timing of invasive airway placement with outcomes after pediatric in-hospital cardiac arrest. (Emrath)

Gupta P, Rettiganti M, Gossett JM, et al. Association of presence and timing of invasive airway placement with outcomes after pediatric in-hospital cardiac arrest. Resuscitation. 2015 Jul;92:53-8.

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BACKGROUND: Little data exist regarding the association of presence of an invasive airway before cardiac arrest or early placement of an invasive airway after cardiac arrest with outcomes in children who experience in-hospital cardiac arrest.

METHODS: We conducted a retrospective review of patients aged 1 day to 18 years who received cardiopulmonary resuscitation (CPR) for ≥ 1 min in any of the three intensive care units (ICUs) at a tertiary care, academic children’s hospital between 2002 and 2010. Specific outcomes evaluated included survival to hospital discharge, return of spontaneous circulation (ROSC), 24-h survival, and good neurological status at hospital discharge. We fitted multivariable logistic regression models to evaluate the association between the presence of an invasive airway prior to cardiac arrest and timing of placement of an invasive airway with these outcomes.

RESULTS: Three hundred and ninety-one patients were included. Of these, 197 (51%) patients were already tracheally intubated before the occurrence of cardiac arrest. Median time to intubation was 6 min [interquartile range (IQR): 2, 12] among the 194 patients tracheally intubated following cardiac arrest. We found lower survival to hospital discharge among patients intubated prior to cardiac arrest (intubated vs. non-intubated group, 43% vs. 61%, p < 0.001). After adjusting for patient and event characteristics, presence of an invasive airway prior to cardiac arrest was not associated with a significant improvement in survival to hospital discharge [odds ratio (OR): 0.70, 95% confidence interval (CI): 0.42-1.16, p = 0.17], or good neurological outcomes (OR: 0.60, 95% CI: 0.34-1.05, p = 0.07). Similarly, early placement of an invasive airway after cardiac arrest was also not associated with an improvement in survival to hospital discharge (OR: 1.05, 95% CI: 0.78-1.42, p = 0.73), or good neurological outcomes (OR: 1.08, 95% CI: 0.77-1.53, p = 0.65).

CONCLUSIONS: Our study demonstrates that presence of an invasive airway prior to cardiac arrest or early placement of an invasive airway after cardiac arrest is not associated with an improvement in survival to hospital discharge or good neurological outcomes. Further study of the relationship between invasive airway management and survival following cardiac arrest is warranted.

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Use of tracheostomy in the PICU among patients requiring prolonged mechanical ventilation. (Stockwell)

Wakeham MK, Kuhn EM, Lee KJ, McCrory MC, Scanlon MC. Use of tracheostomy in the PICU among patients requiring prolonged mechanical ventilation. Intensive Care Med. 2014 Jun;40(6):863-70.

PURPOSE: The purpose of the present study is to describe the use of tracheostomy, specifically frequency, timing (in relation to initiation of mechanical ventilation), and associated factors, in a large cohort of children admitted to North American pediatric intensive care units (PICUs) and requiring prolonged mechanical ventilation.

METHODS: This was a retrospective cohort study. De-identified data were obtained from the VPS(LLC) database, a multi-site, clinical PICU database. Admissions between 1 July 2009 and 30 June 2011 were enrolled in the study if the patient required mechanical ventilation for at least 72 h and did not have a tracheostomy tube at initiation of mechanical ventilation.

RESULTS: A total of 13,232 PICU admissions from 82 PICUs were analyzed in the study; of these, 872 (6.6 %) had a tracheostomy tube inserted after initiation of mechanical ventilation. The rate varied significantly (0-13.4 %, p < 0.001) among the 45 PICUs that had 100 or more admissions included in the study. The median time to insertion of a tracheostomy tube was 14.4 days (IQR 7.4-25.7), and it also varied significantly by unit (4.3-30.4 days, p < 0.001) among those that performed at least ten tracheostomies included in the study.

CONCLUSIONS: There is significant variation in both the frequency and time to tracheostomy between the studied PICUs for patients requiring prolonged mechanical ventilation; among those who received a tracheostomy, the majority did so after two or more weeks of mechanical ventilation. Future studies examining tracheostomy benefits, disadvantages, outcomes, and resource utilization of this patient subgroup are indicated.

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