Sedation versus General Anesthesia for Tracheal Intubation in Children with Difficult Airways: A Cohort Study from the Pediatric Difficult Intubation Registry.
Anesthesiology
BACKGROUND:Sedated and awake tracheal intubation approaches are considered safest in adults with difficult airways, but little is known about the outcomes of sedated intubations in children. The primary aim of this study was to compare the first-attempt success rate of tracheal intubation during sedated tracheal intubation versus tracheal intubation under general anesthesia. The hypothesis was that sedated intubation would be associated with a lower first-attempt success rate and more complications than general anesthesia. METHODS:This study used data from an international observational registry, the Pediatric Difficult Intubation Registry, which prospectively collects data about tracheal intubation in children with difficult airways. The use of sedation versus general anesthesia for tracheal intubation were compared. The primary outcome was the first-attempt success of tracheal intubation. Secondary outcomes included the number of intubation attempts and nonsevere and severe complications. Propensity score matching was used with a matching ratio up to 1:15 to reduce bias due to measured confounders. RESULTS:Between 2017 and 2020, 34 hospitals submitted 1,839 anticipated difficult airway cases that met inclusion criteria for the study. Of these, 75 patients received sedation, and 1,764 patients received general anesthesia. Propensity score matching resulted in 58 patients in the sedation group and 522 patients in the general anesthesia group. The rate of first-attempt success of tracheal intubation was 28 of 58 (48.3%) in the sedation group and 250 of 522 (47.9%) in the general anesthesia group (odds ratio, 1.06; 95% CI, 0.60 to 1.87; P = 0.846). The median number of intubations attempts was 2 (interquartile range, 1 to 3) in the sedation group and 2 (interquartile range, 1, 2) in the general anesthesia group. The general anesthesia group had 6 of 522 (1.1%) intubation failures versus 0 of 58 in the sedation group. However, 16 of 58 (27.6%) sedation cases had to be converted to general anesthesia for successful tracheal intubation. Complications were similar between the groups, and the rate of severe complications was low. CONCLUSIONS:Sedation and general anesthesia had a similar rate of first-attempt success of tracheal intubation in children with difficult airways; however, 27.6% of the sedation cases needed to be converted to general anesthesia to complete tracheal intubation. Complications overall were similar between the groups, and the rate of severe complications was low. EDITOR’S PERSPECTIVE:
10.1097/ALN.0000000000004353
Predictive value of the unplanned extubation risk assessment scale in hospitalized patients with tubes.
World journal of clinical cases
BACKGROUND:Critical patients often had various types of tubes, unplanned extubation of any kind of tube may cause serious injury to the patient, but previous reports mainly focused on endotracheal intubation. The limitations or incorrect use of the unplanned extubation risk assessment tool may lead to improper identification of patients at a high risk of unplanned extubation and cause delay or non-implementation of unplanned extubation prevention interventions. To effectively identify and manage the risk of unplanned extubation, a comprehensive and universal unplanned extubation risk assessment tool is needed. AIM:To assess the predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale in inpatients. METHODS:This was a retrospective validation study. In this study, medical records were extracted between October 2020 and September 2021 from a tertiary comprehensive hospital in southwest China. For patients with tubes during hospitalization, the following information was extracted from the hospital information system: age, sex, admission mode, education, marital status, number of tubes, discharge mode, unplanned extubation occurrence, and the Huaxi Unplanned Extubation Risk Assessment Scale (HUERAS) score. Only inpatients were included, and those with indwelling needles were excluded. The best cut-off value and the area under the curve (AUC) of the Huaxi Unplanned Extubation Risk Assessment Scale were been identified. RESULTS:A total of 76033 inpatients with indwelling tubes were included in this study, and 26 unplanned extubations occurred. The patients' HUERAS scores were between 11 and 30, with an average score of 17.25 ± 3.73. The scores of patients with or without unplanned extubation were 22.85 ± 3.28 and 17.25 ± 3.73, respectively ( < 0.001). The results of the correlation analysis showed that the correlation coefficients between each characteristic and the total score ranged from 0.183 to 0.843. The best cut-off value was 21, and there were 14135 patients with a high risk of unplanned extubation, accounting for 18.59%. The Cronbach's , sensitivity, specificity, positive predictive value, and negative predictive value of the Huaxi Unplanned Extubation Risk Assessment Scale were 0.815, 84.62%, 81.43%, 0.16%, and 99.99%, respectively. The AUC of HUERAS was 0.851 (95%CI: 0.783-0.919, < 0.001). CONCLUSION:The HUERAS has good reliability and predictive validity. It can effectively identify inpatients at a high risk of unplanned extubation and help clinical nurses carry out risk screening and management.
10.12998/wjcc.v10.i36.13274
Reducing Pediatric Unplanned Extubation Across Multiple ICUs Using Quality Improvement.
Pediatrics
OBJECTIVES:Unplanned extubation (UE) in pediatric patients can result in significant harm or mortality. In our institution, efforts to reduce UE in the ICU were siloed and learnings were not shared. Our goal was to implement shared initiatives across ICUs in a pediatric institution using quality improvement methodology, with the global aim of reducing serious harm caused by UEs. METHODS:The study was conducted as a single-center prospective quality improvement initiative in the pediatric, neonatal, and cardiac ICUs of a large, freestanding academic pediatric hospital. Using the model for improvement and plan-do-study-act cycles, our multidisciplinary team implemented multiple interventions to reduce UEs. The primary measure monitored was the monthly UE rate, defined as the number of UEs per 100 ventilator days, which was tracked over time using statistical control charts. RESULTS:The overall monthly institutional UE rate was reduced from 1.22 UE per 100 ventilator days to 0.2 UE per 100 ventilator days, representing an 84% improvement in rate and reduction of harm. Sixteen percent to 21% of UEs required additional resources because of a difficult airway, and 10% to 22% of UEs resulted in cardiovascular collapse requiring resuscitation. CONCLUSIONS:Significant harm is associated with UEs in pediatric patients. We implemented a bundle for UE reduction across all ICU populations in a pediatric hospital and significantly reduced the rate of UE within our institution and within each individual unit. Allowing variation for implementation of interventions by unit, although targeting a common goal, contributed to overall success and sustainability.
10.1542/peds.2021-052259
Pediatric unplanned extubation risk score: A predictive model for risk assessment.
Heart & lung : the journal of critical care
BACKGROUND:Unplanned extubation is one of the most common preventable adverse events associated with invasive mechanical ventilation. OBJECTIVE:This research study aimed to develop a predictive model to identify the risk of unplanned extubation in a pediatric intensive care unit (PICU). METHODS:This single-center, observational study was conducted at the PICU of the Hospital de Clínicas. Patients were included based on the following criteria: aged between 28 days and 14 years, intubated, and using invasive mechanical ventilation. RESULTS:Over 2 years, 2,153 observations were made using the Pediatric Unplanned Extubation Risk Score predictive model. Unplanned extubation occurred in 73 of 2,153 observations. A total of 286 children participated in the application of the Risk Score. This predictive model was created to categorize the following significant risk factors: 1) inadequate placement and fixation of the endotracheal tube (odds ratio 2.00 [95%CI,1.16-3.36]), 2) Insufficient level of sedation (odds ratio 3.00 [95%CI,1.57-4.37]), 3) age ≤ 12 months (odds ratio 1.27 [95%CI,1.14-1.41]), 4) presence of airway hypersecretion (odds ratio 11.00 [95%CI,2,58-45.26]) inadequate family orientation and/or nurse to patient ratio (odds ratio 5.00 [95%CI,2.64-7.99]), and 6) weaning period from mechanical ventilation (odds ratio 3.00 [95%CI,1.67-4.79]) and 5 risk enhancement factors. CONCLUSIONS:The scoring system demonstrated effective sensitivity for estimating the risk of UE with the observation of six aspects, which overlap as an isolated risk factor or are associated with a risk enhancement factors.
10.1016/j.hrtlng.2023.05.021
Unplanned extubation in the NICU.
Barber Jessica A
Journal of obstetric, gynecologic, and neonatal nursing : JOGNN
Unplanned extubation (UE) in the neonatal intensive care unit (NICU) is a significant patient safety and quality control issue. I describe the implementation of a quality improvement program using multifactorial prevention strategies, including staff education, identification of neonates at risk for UE, extubation and weaning, standardization of procedures, and comprehensive documentation. Additional research on quality improvement with strategies for neonates may prove beneficial in reducing UE rates in neonates.
10.1111/1552-6909.12009
Unplanned Extubation in the Pediatric Intensive Care Unit.
Critical care nursing clinics of North America
Unplanned extubations (UEs) are common, potentially avoidable complications of endotracheal intubation among pediatric patients. UE can be associated with adverse patient outcomes including increased length of stay, hospitalization cost, and cardiorespiratory decompensation. Inconsistency in the definition of UE has led to underreporting. Staff must be able to recognize and intervene appropriately when an UE occurs. Risk factors have been identified and quality improvement initiatives aimed at reducing UE have shown to be effective in reducing the incidence. The lack of consistent definition may lead to underreporting and may not lead to effective quality improvement initiatives.
10.1016/j.cnc.2023.04.004
Analytical Review of Unplanned Extubation in Intensive Care Units and Recommendation on Multidisciplinary Preventive Approaches.
Journal of intensive care medicine
Unplanned extubations (UE) frequently occur in critical care units. These events are precipitated by many risk factors and are associated with adverse outcomes for patients. We reviewed the current literature to examine factors related to UE and presented the analysis of 41 articles critical to the topic. Our review has identified specific risk factors that we discuss in this review, such as sedation strategies, physical restraints, endotracheal tube position, and specific nursing care aspects associated with an increased incidence of UE. We recommend interventions to reduce the risk of UE. However, we recommend that bundled rather than a single intervention is likely to yield higher success, given the heterogeneity of factors contributing to increasing the risk of UE.
10.1177/08850666231199055
Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children.
Klugman Darren,Melton Kristin,Maynord Patrick O'Neal,Dawson Aaron,Madhavan Gowri,Montgomery Vicki Lee,Nock Mary,Lee Anthony,Lyren Anne
JAMA pediatrics
Importance:Unplanned extubations (UEs) in children contribute to significant morbidity and mortality, with an arbitrary benchmark target of less than 1 UE per 100 ventilator days. However, there have been no multicenter initiatives to reduce these events. Objective:To determine if a multicenter quality improvement initiative targeting all intubated neonatal and pediatric patients is associated with a reduction in UEs and morbidity associated with UE events. Design, Setting, and Participants:This multicenter quality improvement initiative enrolled patients from pediatric, neonatal, and cardiac intensive care units (ICUs) in 43 participating children's hospitals from March 2016 to December 2018. All patients with an endotracheal tube requiring mechanical ventilation were included in the study. Interventions:Participating hospitals implemented a quality improvement bundle to reduce UEs, which included standardized anatomic reference points and securement methods, protocol for high-risk situations, and multidisciplinary apparent cause analyses. Main Outcomes and Measures:The main outcome measures for this study included bundle compliance with each factor tested and UE rates on the center level and on the cohort level. Results:Among the 43 children's hospitals, the quality improvement initiative was associated with an aggregate 24.1% reduction in UE events, from a baseline rate of 1.135 UEs per 100 ventilator days to 0.862 UEs per 100 ventilator days. Across ICU settings studied, the pediatric ICU and neonatal ICU demonstrated centerline shifts, with an absolute reduction in events of 20.6% (from a baseline rate of 0.729 UEs per 100 ventilator days to 0.579 UEs per 100 ventilator days) and 17.6% (from a baseline rate of 1.555 UEs per 100 ventilator days to 1.282 UEs per 100 ventilator days), respectively. Most UEs required reintubation within 1 hour (mean of 120 of 206 events per month [58.3%]), followed by UEs that did not require reintubation (mean of 78 of 206 events per month [37.9%]) and UEs that resulted in cardiovascular collapse (mean of 8 of 206 events per month [3.9%]). Cardiovascular collapse events represented the most significant consequence of UE studied, and the collaborative reduced these UE events by 36.6%, from a study baseline rate of 0.041 UEs per 100 ventilator days to 0.026 UEs per 100 ventilator days. Conclusions and Relevance:This multicenter quality improvement initiative was associated with a reduction in UEs across different pediatric populations in diverse settings. A significant reduction in event rate and rate of harm (cardiovascular collapse) was observed, which was sustained over the time course of the intervention. This quality improvement process and UE bundle may be considered standard of care for pediatric hospitals in the future.
10.1001/jamapediatrics.2020.0268
Extra-intestinal manifestations of inflammatory bowel diseases.
Marotto Daniela,Atzeni Fabiola,Ardizzone Sandro,Monteleone Giovanni,Giorgi Valeria,Sarzi-Puttini Piercarlo
Pharmacological research
Inflammatory bowel disease (IBDs), including the two main subtypes of Crohn's disease and ulcerative colitis, not only affects the gastrointestinal system, but also has a wide range of extra-intestinal manifestations (EIMs) that are major sources of morbidity and disability, and therefore represent what can be considered a real syndrome. The pathogenetic mechanisms underlying these EIMs are unknown, but some may share a common pathogenesis with IBD and others may be due to IBD treatment. The aim of this review is to examine our current knowledge of IBD EIMs and their treatment.
10.1016/j.phrs.2020.105206
Management of Complications in Crohn's Disease.
Advances in surgery
Complications of Crohn's disease reach far beyond postsurgical leak, infection, and enterocutaneous fistula. Malnutrition, intestinal failure, and recurrent disease all will require ongoing attentions. The management of these patients may further be complicated by the need for chronic immunosuppression. The underlying principles continue to include optimization of nutritional status, and preservation of bowel length when possible. However, there have been several recent advances in both the medical and surgical management of the disease. Understanding the contribution of the mesentery to inflammation, new surgical techniques such as the Kono-S anastomosis and extended mesenteric resection is decreasing the need for repeated resections.
10.1016/j.yasu.2024.04.002