Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival
Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival
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DOI：
10.1001/jama.2016.14486
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发表时间：
2016-11-01
影响因子：
120.7
通讯作者：
Donnino, Michael W.
中科院分区：
文献类型：
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作者：
Andersen, Lars W.;Raymond, Tia T.;Donnino, Michael W.
重要意义气管插管在儿科院内心脏骤停中是常见的，但在心跳骤停期间插管与预后之间的关系尚不清楚。目的确定儿科院内心脏骤停期间气管插管是否与改善预后相关。设计、设置和参与者对GET指南-复苏登记中来自美国医院的数据进行观察性研究。纳入2000年1月至2014年12月期间住院心脏骤停的儿科患者(年龄18岁)。在心脏骤停时正在接受辅助呼吸、有创气道存在或两者兼而有之的患者被排除在外。主要结果和衡量标准是存活至出院。次要结果包括自主循环恢复和神经学结果。良好的神经学结果被定义为在儿童脑功能类别评分中的1到2分。根据多个患者、事件和医院特征计算的随时间变化的倾向评分，将在任何给定分钟内插管的患者与在相同分钟内(即仍在接受复苏)的风险患者进行匹配。结果研究包括2294名患者；1308名(57%)为男性，所有年龄组的代表(中位数年龄为7个月[第25-75个百分位数，21天，4岁])。在纳入的2294名患者中，1555名(68%)在心脏骤停期间插管。在倾向评分匹配的队列中(n=2270)，插管者的生存率低于未插管者(411/1135[36%]比460/1135[41%]；风险比[RR]，0.89[95%CI，0.81-0.99]；P=0.03)。两组患者自主循环恢复(770/1135[68%]vs 771/1135[68%]；RR，1.00[95%CI，0.95~1.06]；P=.96)及神经功能恢复良好(185/987[19%]vs 211/983[21%]；RR，0.87[95%CI，0.75~1.02]；P=0.08)差异无统计学意义。在大多数敏感性和亚组分析中观察到插管和存活率下降之间的关联，包括在考虑缺失数据的情况下，以及在事件开始时有脉搏的患者亚组中。结论在住院心脏骤停的儿科患者中，与不插管相比，在心脏骤停期间插管与出院时存活率降低相关。尽管研究设计没有消除混淆的可能性，但这些发现并不支持目前对儿科住院心脏骤停早期气管插管的重视。
IMPORTANCE Tracheal intubation is common during pediatric in-hospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown.OBJECTIVE To determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes.DESIGN, SETTING, AND PARTICIPANTS Observational study of data from United States hospitals in the Get With The Guidelines-Resuscitation registry. Pediatric patients (< 18 years) with index in-hospital cardiac arrest between January 2000 and December 2014 were included. Patients who were receiving assisted ventilation, had an invasive airway in place, or both at the time chest compressions were initiated were excluded.EXPOSURES Tracheal intubation during cardiac arrest.MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and neurologic outcome. A favorable neurologic outcome was defined as a score of 1 to 2 on the pediatric cerebral performance category score. Patients being intubated at any given minute were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.RESULTS The study included 2294 patients; 1308 (57%) were male, and all age groups were represented (median age, 7 months [25th-75th percentiles, 21 days, 4 years]). Of the 2294 included patients, 1555 (68%) were intubated during the cardiac arrest. In the propensity score-matched cohort (n = 2270), survival was lower in those intubated compared with those not intubated (411/1135 [36%] vs 460/1135 [41%]; risk ratio [RR], 0.89 [95% CI, 0.81-0.99]; P =.03). There was no significant difference in return of spontaneous circulation (770/1135 [68%] vs 771/1135 [68%]; RR, 1.00 [95% CI, 0.95-1.06]; P =.96) or favorable neurologic outcome (185/987 [19%] vs 211/983 [21%]; RR, 0.87 [95% CI, 0.75-1.02]; P =.08) between those intubated and not intubated. The association between intubation and decreased survival was observed in the majority of the sensitivity and subgroup analyses, including when accounting for missing data and in a subgroup of patients with a pulse at the beginning of the event.CONCLUSIONS AND RELEVANCE Among pediatric patients with in-hospital cardiac arrest, tracheal intubation during cardiac arrest compared with no intubation was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding, these findings do not support the current emphasis on early tracheal intubation for pediatric in-hospital cardiac arrest.