Tracheal Intubations for Critically Ill Children Outside Specialized Centers in the United Kingdom-Patient, Provider, Practice Factors, and Adverse Events.
Tracheal Intubations for Critically Ill Children Outside Specialized Centers in the United Kingdom-Patient, Provider, Practice Factors, and Adverse Events.
复制标题
英国专科中心外危重儿童的气管插管——患者、提供者、实践因素和不良事件。
DOI：
10.1097/pcc.0000000000001946
复制
发表时间：
2019
期刊：
影响因子：
--
通讯作者：
Nishisaki,Akira
中科院分区：
文献类型：
--
作者：
SandersJr,Ron;Edwards,Lauren;Nishisaki,Akira
在患病的儿科患者中进行呼吸道管理在许多层面上都是一种应激事件。具体地说，患者、提供者和实践因素对呼吸道管理的结果有重大影响。通常，在危急情况下，患儿会出现顽固性缺氧或高碳酸血症、低血压、饱腹症，以及缺乏经验的工作人员(直接呼吸道提供者和辅助人员)和有限的呼吸道设备选择(例如，无法使用视频喉镜或喉罩作为抢救设备)的不良环境。这些不理想的患者、提供者和执业条件将增加不良事件和并发症，即使在最好的手(即，训练有素的，董事会认证的麻醉师)。在多中心PICU数据库中，大多数数据来自美国，16%-20%的儿科气管插管(TIS)与不良事件(1-4)有关。在本期《儿科危重护理医学》中，Matettore等人(5)报道了他们的多中心前瞻性观察研究，跟踪了在英国泰晤士河北部和东英吉利地区的47家非专科当地医院进行的为期24个月的TIS治疗。他们评估了不良感染相关事件(TIAEs)，包括不严重的TIAEs，如气管(主干)插管、呼吸道损伤、心动过缓、高血压、心动过速和意想不到的困难的呼吸道，以及严重的TIAEs，如食道插管、缺氧(外周毛细血管血氧饱和度在2分钟内达90%)、心脏骤停、胃内容物吸入、气胸、低血压、外科呼吸道、“不能插管、不能呼吸”和“不能插管、不能呼吸”。心动过缓、心动过速、低血压和高血压有特定年龄的标准。他们能够分析符合条件的1237名患者中的1051名患者。不良TIAEs发生率为22.7%。这一TIAE的发生率似乎高于PICU和心脏ICU，可能是由于以下原因：1)他们的TIAE定义包括缺氧，而国家儿童急诊呼吸道登记处(NEAR4KIDS)单独报告了缺氧；2)他们的患者可能病情更严重，因为大多数TIS是紧急和紧急的适应症，而来自NEAR4KID的PICU插管包括15-20%的“程序性”插管(4，6)。考虑到绝大多数插管是由他们队列中的麻醉师执行的，如果他们的提供者中的大多数是非麻醉师实习生，他们的不良反应发生率可能会更高。他们发现，45%的患者有既往的合并症。最常见的诱导剂包括芬太尼、氯胺酮和异丙酚，而琥珀胆碱是最常见的神经肌肉阻滞剂。最常见的非严重TIAE包括气管插管、心动过缓和意想不到的困难的呼吸道。主要的严重TIAE包括低血压、低氧和食道插管。心脏骤停的发生率为1.6%，这与PICU中的TIS惊人地相似(7)。他们的发现类似于Easley等人(8)，他们对美国社区医院、急诊科和儿童医院急诊科的244名儿童进行了前瞻性研究，发现37%的患者在儿童医院外插管时出现了重大和微小的差异。毫不奇怪，呼吸道困难程度较高的儿童经历了更多的并发症。合并TIAE的患者在TI期间更有可能遭受严重的TIAE。有趣的是，…的系统因素
Performing airway management in a sick pediatric patient is a stressful event on many levels. Specifically patient, provider, and practice factors have substantial impact in the outcomes of airway management. Oftentimes, the child presents in extremis with refractory hypoxia or hypercarbia, hypotension, and a full stomach to an inauspicious setting with less-experienced staff (direct airway provider as well as supporting staff) and a limited selection of airway devices (eg, unavailability of video laryngoscopy or laryngeal mask as a rescue device). These suboptimal patient, provider, and practice conditions will increase adverse events and complications even in the best of hands (ie, trained, board-certified anesthesiologist). In the multicenter PICU database, with the majority of data from the United States, 16–20% of pediatric tracheal intubations (TIs) are associated with adverse events (1–4) In this issue of Pediatric Critical Care Medicine, Matettore et al (5) reported their multicenter prospective observational study that tracked TIs that were performed in children (0–16 yr old) at 47 nonspecialized local hospitals in the North Thames and East Anglia region of the United Kingdom over a24-month period. They evaluated adverse TI-associated events (TIAEs), which included those categorized as nonsevere, such as endobronchial (mainstem) intubation, airway trauma, bradycardia, hypertension, tachycardia, and unanticipated difficult airway, as well as severe TIAEs, such as esophageal intubation, hypoxia (peripheral capillary hemoglobin oxygen saturation< 90% for> 2 min), cardiac arrest, aspiration of gastric contents, pneumothorax, hypotension, surgical airway,“Can’t intubate, CAN ventilate,” and “Can’t intubate; CANNOT ventilate.” Bradycardia, tachycardia, hypotension, and hypertension had age-specific criteria.They were able to analyze 1,051 patients out of the eligible 1,237 patients. Adverse TIAEs occurred in 22.7% of the patients. This TIAE rate seems higher than those in PICUs and cardiac ICUs, likely due to the following reasons: 1) their TIAE definitions include hypoxia whereas the National Emergency Airway Registry for Children (NEAR4KIDS) reports hypoxia separately and 2) their patient population may be more acutely ill, as most TIs are for urgent and emergent indications, whereas PICU intubations from NEAR4KIDS include 15–20% as “procedural” intubations (4, 6). Given that the overwhelming majority of intubations were performed by an anesthesiologist in their cohort, their adverse TIAE rates may have been higher if the majority of their providers were nonanesthesiologist trainees. They found that 45% of the patients had preexisting comorbidities. The most common induction agents included fentanyl, ketamine, and propofol, whereas succinylcholine was the most common neuromuscular blocking agent. The most common nonsevere TIAEs included endobronchial intubation, bradycardia, and unanticipated difficult airway. The predominant severe TIAEs included hypotension, hypoxia, and esophageal intubation. Cardiac arrest occurred 1.6% of the time, which is surprisingly similar to TIs in the PICUs (7). Their findings were similar to Easley et al (8) who conducted a prospective study of 244 children intubated in community hospitals, emergency departments, and children’s hospital emergency departments in the United States, finding that major and minor variances occurred in 37% of patients who were intubated outside of a children’s hospital. Not surprisingly, children with a higher grade of airway difficulty experienced more complications. Patients with comorbidities were more likely to suffer severe TIAEs during TI. Interestingly, system factors …