Use Of Endotracheal Intubation Research Articles

SOFA in sepsis: with or without GCS

PurposeSepsis is a global public health burden. The sequential organ failure assessment (SOFA) is the most commonly used scoring system for diagnosing sepsis and assessing severity. Due to the widespread use of endotracheal intubation and sedative medications in sepsis, the accuracy of the Glasgow Coma Score (GCS) is the lowest in SOFA. We designed this multicenter, cross-sectional study to investigate the predictive efficiency of SOFA with or without GCS on ICU mortality in patients with sepsis.MethodsFirst, 3048 patients with sepsis admitted to Peking Union Medical College Hospital (PUMCH) were enrolled in this survey. The data were collected from June 8, 2013 to October 12, 2022. Second, 18,108 patients with sepsis in the eICU database were enrolled. Third, 2397 septic patients with respiratory system ≥ 3 points in SOFA in the eICU database were included. We investigated the predictive efficiency of SOFA with or without GCS on ICU mortality in patients with sepsis in various ICUs of PUMCH, and then we validated the results in the eICU database.Main resultsIn data of ICUs in PUMCH, the predictive efficiency of SOFA without GCS (AUROC [95% CI], 24 h, 0.724 [0.688, 0.760], 48 h, 0.734 [0.699, 0.769], 72 h, 0.748 [0.713, 0.783], 168 h, 0.781 [0.747, 0.815]) was higher than that of SOFA with GCS (AUROC [95% CI], 24 h, 0.708 [0.672, 0.744], 48 h, 0.721 [0.685, 0.757], 72 h, 0.735 [0.700, 0.757], 168 h, 0.770 [0.736, 0.804]) on ICU mortality in patients with sepsis, and the difference was statistically significant (P value, 24 h, 0.001, 48 h, 0.003, 72 h, 0.004, 168 h, 0.005). In septic patients with respiratory system ≥ 3 points in SOFA in the eICU database, although the difference was not statistically significant (P value, 24 h, 0.148, 48 h, 0.178, 72 h, 0.132, 168 h, 0.790), SOFA without GCS (AUROC [95% CI], 24 h, 0.601 [0.576, 0.626], 48 h, 0.625 [0.601, 0.649], 72 h, 0.639 [0.615, 0.663], 168 h, 0.653 [0.629, 0.677]) had a higher predictive efficiency on ICU mortality than SOFA with GCS (AUROC [95% CI], 24 h, 0.591 [0.566, 0.616], 48 h, 0.616 [0.592, 0.640], 72 h, 0.628 [0.604, 0.652], 168 h, 0.651 [0.627, 0.675]).ConclusionsIn severe sepsis, it is realistic and feasible to discontinue the routine GCS for SOFA in patients with a respiratory system ≥ 3 points, and even better predict ICU mortality.

In-hospital mortality after prehospital endotracheal intubation versus alternative methods of airway management in trauma patients. A cohort study from the TraumaRegister DGU®.

Prehospital airway management in trauma is a key component of care and is associated with particular risks. Endotracheal intubation (ETI) is the gold standard, while extraglottic airway devices (EGAs) are recommended alternatives. There is limited evidence comparing their effectiveness. In this retrospective analysis from the TraumaRegister DGU®, we compared ETI with EGA in prehospital airway management regarding in-hospital mortality in patients with trauma. We included cases only from German hospitals with a minimum Abbreviated Injury Scale score ≥ 2 and age ≥ 16 years. All patients without prehospital airway protection were excluded. We performed a multivariate logistic regression to adjust with the outcome measure of hospital mortality. We included n = 10,408 cases of whom 92.5% received ETI and 7.5% EGA. The mean injury severity score was higher in the ETI group (28.8 ± 14.2) than in the EGA group (26.3 ± 14.2), and in-hospital mortality was comparable: ETI 33.0%; EGA 30.7% (27.5 to 33.9). After conducting logistic regression, the odds ratio for mortality in the ETI group was 1.091 (0.87 to 1.37). The standardized mortality ratio was 1.04 (1.01 to 1.07) in the ETI group and 1.1 (1.02 to 1.26) in the EGA group. There was no significant difference in mortality rates between the use of ETI or EGA, or the ratio of expected versus observed mortality when using ETI.

Excessive Use of Benzodiazepines Is a Risk Factor for Endotracheal Intubation in Children Who Present to Emergency With Prehospital Status Epilepticus.

There is lack of evidence-based information on the use and timing of endotracheal intubation (ETI) in children with prehospital status epilepticus (SE). The aim of this study was to investigate ETI use, timing, risk factors, and outcomes in children presenting to a single-center children's emergency (CE) with prehospital SE, over a 5-year period. A total of 118 events involving children presenting to CE with ongoing prehospital SE were included, and 39% (46/118) of the events required ETI. The most common indication for ETI was respiratory depression. The median time to intubation after arrival at CE was 20.0 minutes (1-155 minutes). Risk factors associated with ETI use include the administration of more than 2 benzodiazepines (26.1% vs 4.2%, P < 0.001) and the use of second- or third-line antiepileptic therapy ( P < 0.001). The use of more than 2 doses of benzodiazepines was found in 12.7% (15/118) of the patients. In patients who received excessive benzodiazepines, 87% (13/15) of them required intubation. Excessive use of benzodiazepine was found to be a main risk factor for ETI in patients with prehospital SE. Avoidance of the excessive use of benzodiazepines and adhering to clinical management guidelines may reduce the risk for ETI in the CE. The best approach to airway management in children with prehospital SE is lacking and urgently needed.

Strategies of Advanced Airway Management in Out-of-Hospital Cardiac Arrest during Intra-Arrest Hypothermia: Insights from the PRINCESS Trial.

Trans-nasal evaporative cooling is an effective method to induce intra-arrest therapeutic hypothermia in out-of-hospital cardiac arrest (OHCA). The use of supraglottic airway devices (SGA) instead of endotracheal intubation may enable shorter time intervals to induce cooling. We aimed to study the outcomes in OHCA patients receiving endotracheal intubation (ETI) or a SGA during intra-arrest trans-nasal evaporative cooling. This is a pre-specified sub-study of the PRINCESS trial (NCT01400373) that included witnessed OHCA patients randomized during resuscitation to trans-nasal intra-arrest cooling vs. standard care followed by temperature control at 33 °C for 24 h. For this study, patients randomized to intra-arrest cooling were stratified according to the use of ETI vs. SGA prior to the induction of cooling. SGA was placed by paramedics in the first-tier ambulance or by physicians or anesthetic nurses in the second tier while ETI was performed only after the arrival of the second tier. Propensity score matching was used to adjust for differences at the baseline between the two groups. The primary outcome was survival with good neurological outcome, defined as cerebral performance category (CPC) 1-2 at 90 days. Secondary outcomes included time to place airway, overall survival at 90 days, survival with complete neurologic recovery (CPC 1) at 90 days and sustained return of spontaneous circulation (ROSC). Of the 343 patients randomized to the intervention arm (median age 64 years, 24% were women), 328 received intra-arrest cooling and had data on the airway method (<i>n</i> = 259 with ETI vs. <i>n</i> = 69 with SGA). Median time from the arrival of the first-tier ambulance to successful airway management was 8 min for ETI performed by second tier and 4 min for SGA performed by the first or second tier (<i>p</i> = 0.001). No significant differences in the probability of good neurological outcome (OR 1.43, 95% CI 0.64-3.01), overall survival (OR 1.26, 95% CI 0.57-2.55), full neurological recovery (OR 1.17, 95% CI 0.52-2.73) or sustained ROSC (OR 0.88, 95% CI 0.50-1.52) were observed between ETI and SGA. Among the OHCA patients treated with trans-nasal evaporative intra-arrest cooling, the use of SGA was associated with a significantly shorter time to airway management and with similar outcomes compared to ETI.

The Utilization of Critical Care Resources in Pediatric Neurocritical Care Patients.

To define the prevalence of neurologic diagnoses and evaluate the utilization of critical care and neurocritical care (NCC) resources among children admitted to the PICU. Retrospective cohort analysis. Data submitted to the Virtual Pediatric Systems (VPS) database. All children entered in VPS during 2016 (January 1, 2016, to December 31, 2016). None. There were 128,688 patients entered into VPS and were comprised of 24.3% NCC admissions and 75.7% general PICU admissions. The NCC cohort was older, represented more scheduled admissions, and was more frequently admitted from the operating room. The NCC cohort also experienced a greater decline in prehospitalization to posthospitalization functional status and required more frequent use of endotracheal intubation, arterial lines, and foley catheters but had an overall shorter duration of PICU and hospital length of stay with a higher mortality rate. One thousand seven hundred fifteen patients at 12 participating institutions were entered into a novel, pilot NCC module evaluating sources of secondary neurologic injury. Four hundred forty-eight patients were manually excluded by the data entrant, leaving 1,267 patients in the module. Of the patients in the module, 75.8% of patients had a NCC diagnosis as their primary diagnosis; they experienced a high prevalence of pathophysiologic events associated with secondary neurologic insult (ranging from hyperglycemia at 10.5% to hyperthermia at 36.8%). In children admitted to a VPS-contributing PICU, a diagnosis of acute neurologic disease was associated with greater use of resources. We have identified the most common etiologies of acute neurologic disease in the 2016 VPS cohort, and such admissions were associated with significant decrease in functional status, as well as an increase in mortality.

Do Mechanically Ventilated COVID-19 Patients Present a Higher Case-Fatality Rate Compared With Other Infectious Respiratory Pandemics? A Systematic Review and Meta-Analysis

Background Early reports on COVID-19 patient outcomes showed a marked fatality rate among patients requiring invasive mechanical ventilation (IMV). Objective Our aim was to compare case fatality rate (CFR) outcomes for patients requiring IMV due to severe acute respiratory syndrome (SARS)-associated coronavirus 2 (COVID-19), SARS-associated coronavirus 1, Middle East respiratory syndrome (MERS), and influenza (H1N1). Materials and Methods We searched PubMed, EMBASE, MEDLINE, Google Scholar, and Cochrane Library for relevant studies published between December 2019 and April 2021 for COVID-19, between January 2002 and December 2008 for SARS, between January 2012 and December 2019 for MERS, and between January 2009 and December 2016 for influenza (H1N1). Results Overall, this study included 81 peer-reviewed studies, pertaining to 65,058 patients requiring IMV: 61 studies including 62,809 COVID-19 patients, 4 studies including 148 SARS patients, 9 studies including 875 MERS patients, and 7 studies including 1226 influenza (H1N1) patients. The CFR for COVID-19 patients requiring IMV was not significantly different from the CFR for SARS and influenza (H1N1) patients (45.5% [95% confidence interval (CI), 38.5%–52.8%] vs. 48.1% [95% CI, 39.2%–57.2%] and 39.7% [95% CI, 29.3%–51.3%], respectively). However, CFR for COVID-19 patients was significantly lower compared with that for MERS patients (CFR, 70.6%; 95% CI, 60.9%–78.8%). Conclusions COVID-19 patients requiring IMV show a similar CFR compared with SARS and H1N1 influenza patients but a lower CFR compared with MERS patients. To improve survival in future pandemics, we recommend examining the pros and cons of the liberal use of endotracheal intubation and considering drafting guidelines for the selection of patients to intubate and the timing of intubation.

Prehospital airway management in the pediatric patient: A systematic review.

Critically ill children may require airway management to optimize delivery of oxygen and ventilation during resuscitation. We performed a systematic review of studies comparing the use of bag-valve-mask ventilation (BVM), supraglottic airway devices (SGA), and endotracheal intubation (ETI) in pediatric patients requiring prehospital airway management. We searched Ovid MEDLINE, EMBASE, and Cochrane databases for papers that compared SGA or ETI to BVM use in children, including studies that reported survival outcomes. We followed the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed study quality using the Newcastle-Ottawa Scale. We compared key characteristics of the candidate papers, including inclusion criteria, definitions of airway interventions, and association with outcomes. Of 773 studies, eight met criteria for inclusion. Only one study was a randomized controlled trial; the other seven studies were observational. Four studies compared ETI to BVM, two studies compared SGA to BVM, one study compared ETI to SGA, and two studies compared advanced airway management (AAM) to BVM. Primary outcomes varied, ranging from overall mortality and 24-h mortality to 1-month survival, hospital survival, and neurologically favorable survival. Four of the studies found no difference in survival with the use of ETI, and four found increased mortality with the use of ETI. Associations with outcomes could not be assessed by meta-analysis due to limited number of studies and the wide variation in the design, population, interventions, and outcome measures of the included studies. In this systematic review, studies of prehospital pediatric airway management varied in scope, design, and conclusions. There was insufficient evidence to evaluate efficacy of pediatric prehospital airway management; however, the current research suggests that there are equal or worse outcomes with the use of ETI compared to other airway techniques. Additional clinical trials are needed to assess the merits of this practice.

Endotracheal Intubation Versus No Endotracheal Intubation During Cardiopulmonary Arrest in the Emergency Department.

BackgroundThere is a lack of studies addressing the short and long-term outcomes of using different airway interventions in patients with cardiopulmonary arrest in the emergency department (ED). This retrospective chart review aimed to investigate the effect of endotracheal intubation (ETI) versus no ETI during cardiopulmonary arrest in the ED on return of spontaneous circulation (ROSC) and survival to discharge.MethodologyA total of 168 charts were reviewed from August 2017 to April 2019. Resuscitation characteristics were obtained from Utstein-style-based cardiopulmonary arrest flow sheets.ResultsUnadjusted analysis showed no difference in ROSC (45.5% in ETI vs. 54.5% in no-ETI) (p = 0.08) and survival to hospital discharge at 28 days (26.7% in ETI vs. 73.3% in non-ETI) (p = 0.07) when comparing ETI versus non-ETI airway management methods during cardiopulmonary resuscitation (CPR). After adjusting for confounding factors, our regression analysis revealed that the use of ETI is associated with lower odds of ROSC (odds ratio [OR] = 3.40, 95% confidence interval [CI] = [0.14-0.84]) and survival to hospital discharge at 28 days (OR = 0.20, 95% CI = [0.04-0.84]).ConclusionsETI during CPR in the ED is associated with worse ROSC and survival to hospital discharge at 28 days.

Abstract 13071: Supraglottic Airway Devices Are Associated With Asphyxial Physiology Upon Arrival for ECPR in Patients With Refractory OHCA Treated With Prolonged CPR

Introduction: Multiple clinical trials have failed to show significant differences in survival between use of endotracheal intubation (ETI) and supraglottic airway devices (SGA) in patients with out-of-hospital cardiac arrest (OHCA). However, treatment in these trials was limited to standard ACLS, which favors short duration of CPR. We sought to compare the physiological effect of ETI versus SGA use in patients treated with prolonged CPR and extracorporeal pulmonary resuscitation (ECPR) for refractory ventricular fibrillation/ventricular tachycardia (VT/VF) by the Minnesota Mobile Resuscitation Consortium (MMRC). Methods: Consecutive refractory VT/VF OHCA patients transported by the MMRC to the University of Minnesota for ECPR between 2015 and 2021 were included in this retrospective analysis. Patients were considered ineligible for ECPR if they failed specific arterial blood gas metabolic criteria (lactic acid &gt;18 mmol/L, PaO2 &lt;50 mmHg, and ETCO2 &lt;10 mmHg). Metabolic parameters at presentation and survival were compared between patients receiving ETI and SGA. Results: Among 260 patients (58.0±11.8 years), 46.5% received ETI and 53.5% received SGA. During the index hospitalization, 78/260 (30%) achieved neurologically favorable survival. Compared to those receiving ETI, patients receiving SGA had lower PaO2 (116.8±118.7 versus 135.8±128.3 mmHg, p=0.03), higher PaCO2 (69.7±28.9 versus 60.7±25.6 mmHg, p=0.01), and lower pH (7.00±0.19 versus 7.06±0.21, p=0.008). Significantly more patients who received SGA had PaO2 &lt;50mmHg (29.1% versus 16.9%, respectively; p=0.02) and ≥1 ECPR exclusion criteria (33.1% versus 20.7%, respectively; p=0.03). Among patients excluded for PaO2 &lt;50 mmHg, the presenting PaO2 was 35.5±11.0 mmHg and the presenting PaCO2 was 94.5±26.2 mmHg, suggestive of absence of effective ventilation (asphyxia) at presentation. Survival with CPC 1-2 was 34.7% versus 25.9% for ETI versus SGA, respectively (p=0.12). Conclusion: Use of SGA, during prolonged CPR in refractory VT/VF OHCA, was associated with a significant increase in the proportion of patients presenting with significant hypoxemia and asphyxial physiology, thus increasing ineligibility for ECPR.

The experience of an emergency intensive care unit during the COVID-19 pandemic: A retrospective cohort study

Aim: The availability of an intensive care unit in the emergency departments (EDICU) is one of the most important issues discussed recently in terms of increasing the quality of emergency patient care. In this study, we aimed to investigate the clinical characteristics and factors affecting the mortality in patients with COVID-19. Material and Methods: This is a retrospective study of patients with COVID-19 hospitalized in EDICU. Patients were divided into mortality and survival groups, and the clinical characteristics of these groups were compared. Results: A total of 38 patients were included;47.4% (n = 18) were in the survival group. Oxygen saturation level was significantly different between the mortality and survival groups [78.0% (63.7-83.0) vs 88.5% (81.5-93.2), p = 0.001]. Patients in the mortality group had higher plasma levels of lactate dehydrogenase (LDH), procalcitonin, C-reactive protein (CRP), lactate, ferritin and D-dimer. Univariate regression analysis showed that oxygen saturation, LDH, CRP and endotracheal intubation (ETI) were significant markers in predicting mortality (p = 0.011, p = 0.035, p <0.001, respectively). A CRP level ≥ 91.9 mg/L predicts mortality with a sensitivity of 66.6% and a specificity of 80.0% (AUC: 0.781, 95% CI: 0.617-0,898). Discussion: This study showed that oxygen saturation, ETI, LDH and CRP levels were significantly successful in predicting mortality. Therefore, early administration of antibiotherapy and timely use of ETI may increase the quality of patient care.

Impact of COVID-19-adapted guidelines on resuscitation quality in out-of-hospital-cardiac-arrest: a manikin study.

The aim of this study is to evaluate the effects of European Resuscitation Council (ERC) COVID-19-guidelines on resuscitation quality emphasizing advanced airway management in out-of-hospital-cardiac-arrest. In a manikin study paramedics and emergency physicians performed advanced cardiac life support in three settings: ERC guidelines 2015 (control), COVID-19-guidelines as suggested with minimum staff (COVID-19-minimal-personnel); COVID-19-guidelines with paramedics and an emergency physician (COVID-19-advanced-airway-manager). Main outcome measures were no-flow-time, quality metrics as defined by ERC and time intervals to first chest compression, oxygen supply, intubation and first rhythm analysis. Data were presented as mean±standard deviation. Thirty resuscitation scenarios were completed. No-flow-time was markedly prolonged in COVID-19-minimal-personnel (113±37 s) compared to control (55±9 s) and COVID-19-advanced-airway-manager (76±38s; P<0.001 each). In both COVID-19-groups chest compressions started later (COVID-19-minimal-personnel: 32±6 s; COVID-19-advanced-airway-manager: 37±7 s; each P<0.001 vs. control [21±5 s]), but oxygen supply (COVID-19-minimal-personnel: 29±5 s; COVID-19-advanced-airway-manager: 34±7 s; each P<0.001 vs. control [77±19 s]) and first intubation attempt (COVID-19-minimal-personnel: 111±14 s; COVID-19-advanced-airway-manager: 131±20 s; each P<0.001 vs. control [178±44 s]) were performed earlier. However, time interval to successful intubation was similar (control: 198±48 s; COVID-19-minimal-personnel: 181±42 s; COVID-19-advanced-airway-manager: 130±25 s) due to a longer intubation time in COVID-19-minimal-personnel (61±35 s) compared to COVID-19-advanced-airway-manager (P=0.002) and control (19±6 s; P<0.001). Time to first rhythm analysis was more than doubled in COVID-19-minimal-personnel (138±96 s) compared to control (50±12 s; P<0.001). Delayed chest compressions and prolonged no-flow-time markedly reduced the quality of resuscitation. These negative effects were attenuated by increasing the number of staff and by adding an experienced airway manager. The use of endotracheal intubation for reducing aerosol release during resuscitation should be discussed critically as its priorization is associated with an increase in no-flow-time.

A current guide to airway management in prehospital patient care

A patent airway linking the nose and mouth with the lungs is essential to life. In emergency care, individuals may experience airway difficulties for many reasons including major trauma, airway inflammation and altered consciousness. Airway management is therefore a core skill for paramedics and other practitioners working in prehospital care. This article reviews the anatomy and physiology of the airway before moving on to consider causes of airway obstruction. A look-listen-feel approach to airway assessment is described, followed by a discussion of techniques used to clear, open and maintain the airway. Commonly used airway devices including oropharyngeal, nasopharyngeal and supraglottic airways are evaluated, and their indications and insertion techniques discussed. The use of endotracheal intubation by paramedics is also evaluated.

Occupational allergy to methacrylates: a deadly risk in workplace

Allergic contact dermatitis (ACD) caused by (meth) acrylates (MA) is common in exposed persons. Moreover, Exposure to MA may rise the predisposition to rhinitis and asthma. However, the occurrence of both asthma and ACD due to MA in the same patient seems to be exceptional. Aim: Report a case of a complex allergy to MA in workplace and stress the difficulty of professional reclassification. A 36-year-old female worker in an electric factory presented to the department of occupational medicine for rhino conjunctivitis, asthma and ACD. Symptoms of weezing dyspnea, rhino conjunctivitis and ACD appeared a few months after recruitment and followed a professional rythmicity (improved during vacation time and aggravated when return to work). The patient’s occupational history revealed that she used a glue containing Hydroxy ethyl methacrylates. Asthma was diagnosed by spirometry, a reversibility test was positive (the FEV1 went up by 12% and 250 ml), nonspecific inhalation challenge test to methacholin was not performed because of a recent history of inadequately controlled asthma. Exhaled NO revealed bronchial inflammation and eosinophilia. The skin-prick test reactions to common environmental allergens and MA were negative. On patch testing, positive reactions were found to several MA including dimethacrylates ethyglycol (++) and mainly the 2-hydroxyethylmethacrylate (2-HEMA) (++). Diagnosis of occupational asthma, rhino conjunctivitis, and ACD to MA was retained. A professional reclassification prohibiting handling all products containing MA was indicated. While resumption of work, the patient presented two episodes of severe acute asthma with hospitalization in intensive care unit and use of endotracheal intubation. Investigation concluded that effective avoidance of use and exposure to glue was not insured imposing a long work stoppage (3 years). Yet, the patient has suffered from a non-controlled severe asthma. To the best of the authors' knowledge, nowadays, there is only one previous reported case of a dentist with both occupational skin and respiratory hypersensitivity from MAs. The case we reported revealed a serious case of occupational asthma, rhino conjunctivitis and ACD caused by MA and threatening the patient's life. Patients with allergy to MA should stop handling it but in practice, professional reclassification finds its limit in severe immediate hypersensitivity forms.

Development and validation of a nomogram for predicting late-onset sepsis in preterm infants on the basis of thyroid function and other risk factors: Mixed retrospective and prospective cohort study

Preterm birth and infection are common causes of neonatal death. In this study, we aimed to develop a nomogram for assessing the individual prior probability of late-onset sepsis on the basis of risk factors in preterm infants. This study is a mixed retrospective and prospective cohort study conducted in three centers. Data from January 2014 to December 2017 was used for the development cohort, and data from January 2018 to December 2018 was used for the validation cohort. In the development cohort, we identified the predicting variables of late-onset sepsis in preterm infants, from which a nomogram was obtained. Then we built nomograms, for with and without thyroid function, to predict late-onset sepsis. The nomogram was validated in the validation cohort concerning discrimination and calibration. A total of 1256 and 452 preterm infants were included in the development and validation cohort, respectively. We found thyroid hypofunction in preterm infants could increase the incidence of late-onset infection. The prediction model incorporated thyroid function, birth weight, use of endotracheal intubation, and duration of umbilical venous catheters was validated and developed as a nomogram for predicting late-onset sepsis in preterm infants. Nomogram in this study may contribute to clinical assessment and treatment decisions.

Enhanced infection control interventions reduced catheter-related bloodstream infections in the neonatal department of Hung Vuong Hospital, Vietnam, 2011\u20132012: a pre- and post-intervention study

BackgroundCatheter-related bloodstream infections (CR-BSI) cause high neonatal mortality and are related to inadequate aseptic technique during the care and maintenance of a catheter. The incidence of CR-BSI among neonates in Hung Vuong Hospital was higher than that of other neonatal care centres in Vietnam.MethodsAn 18-month pre- and post-intervention study was conducted over three 6-month periods to evaluate the effectiveness of the intervention for CR-BSI and to identify risk factors associated with CR-BSI. During the intervention period, we trained all nurses in the Department of Neonatology on BSI preventive practices, provided auditing and feedback about aseptic technique during catheter care and maintenance, and reorganised preparation of total parenteral nutrition. All neonates with intravenous catheter insertion ≥48 h in the pre- and post-intervention period were enrolled. A standardised questionnaire was used to collect data. Blood samples were collected for cultures. We used Poisson regression to calculate rate ratio (RR) and 95% confidence interval (CI) for CR-BSI incidence rates and logistic regression to identify risk factors associated with CR-BSI.ResultsOf 2225 neonates enrolled, 1027 were enrolled in the pre-intervention period, of which 53 CR-BSI cases occurred in 8399 catheter-days, and 1198 were enrolled in the post-intervention period, of which 32 CR-BSI cases occurred in 8324 catheter-days. Incidence rates of CR-BSI significantly decreased after the intervention (RR = 0.61, 95% CI 0.39–0.94). Days of hospitalisation, episodes of non-catheter–related hospital-acquired infections, and the proportion of deaths significantly decreased after the intervention (p < 0.01). The CR-BSI was associated with days of intravenous catheter (odds ratio [OR] = 1.05, 95% CI 1.03–1.08), use of endotracheal intubation (OR = 2.27, 95% CI 1.27–4.06), and intravenous injection (OR = 8.50, 95% CI 1.14–63.4).ConclusionsThe interventions significantly decreased the incidence rate of CR-BSI. Regular refresher training and auditing and feedback about aseptic technique during care and maintenance of catheters are critical to reducing CR-BSI.

Retrospective cohort study of hospital variation in airway management during in-hospital cardiac arrest and the association with patient survival: insights from Get With The Guidelines-Resuscitation

ImportanceThe optimal approach to airway management during in-hospital cardiac arrest is unknown.ObjectiveTo describe hospital-level variation in endotracheal intubation during cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest and the association between hospital use of endotracheal intubation and arrest survival.Design, setting, participantsRetrospective cohort study of adult patients suffering in-hospital cardiac arrest at Get With The Guidelines-Resuscitation participating hospitals between January, 2000, and December, 2016. Hospitals were categorized into quartiles based on the proportion of in-hospital cardiac arrest patients managed with endotracheal intubation during CPR. Risk-adjusted mixed models with random intercepts were created to assess the association between hospital quartile of in-hospital arrests managed with endotracheal intubation during CPR and survival to hospital discharge.ExposureHospital rate of endotracheal intubation during CPR for in-hospital arrestMain outcomes and measuresSurvival to hospital dischargeResultsAmong 155,252 patients suffering in-hospital cardiac arrest at 656 hospitals, 69.7% of patients received endotracheal intubation during CPR and overall survival to discharge was 24.8%. At the hospital level, the median rate of endotracheal intubation use was 71.2% (interquartile range, 63.6 to 78.1%; range, 26.6 to 100%). We found a strong inverse association between hospital rate of endotracheal intubation and survival to discharge (risk-adjusted odds ratio comparing highest intubation quartile vs. lowest intubation quartile, 0.81; 95% confidence interval (CI), 0.74 to 0.90; p value < .001). This association was modified by the presence of respiratory failure prior to arrest (p for interaction < .001), and stratified analyses demonstrated lower patient survival at hospitals with higher rates of endotracheal intubation was limited to patients without respiratory failure prior to cardiac arrest.ConclusionIn a national sample of patients suffering IHCA, the use of endotracheal intubation during CPR varied across hospitals. We found a strong inverse association between hospital use of endotracheal intubation during CPR and survival to discharge, but this association was confined to patients without respiratory failure prior to arrest. Identifying the optimal approach to airway management for in-hospital cardiac arrest may have a significant impact on patient survival.

Unequal Rates of Serious Perioperative Respiratory Adverse Events Between Black and White Children

BackgroundRecent data among pediatric otolaryngology patients showed unexplained higher rates of serious perioperative respiratory adverse events (PRAE) in black children compared to their white peers. We evaluated whether preoperative respiratory comorbidity (PRC) burden contributes to racial disparity in serious PRAE in children undergoing non-otolaryngologic procedures. MethodsRates of serious PRAE (laryngospasm and/or bronchospasm) were compared across racial groups in a retrospective cohort of black and white children (N = 18538; black 10%) who underwent various elective, non-otolaryngologic procedures between 2007 and 2014 at a US tertiary Children's hospital. Self-reported race was the primary exposure while age, gender, recent upper respiratory tract infection, use of endotracheal intubation, PRC burden and an interaction term between PRC and race were covariates. ResultsSerious PRAE occurred in 9.6% of black children and 6.6% of white children. Although there was no significant difference in age between the groups, being black (odds ratio (OR) 1.70; 95% confidence interval (CI) 1.11–2.62) was independently associated with serious PRAE. Similarly, baseline PRC was independently linked (p < 0.001) with serious PRAE. Notably, there was no significant (p = 0.454) interactions between race and PRC and serious PRAE in our subjects. ConclusionRace and PRC are important considerations in the risk of serious PRAE and black children are especially at risk compared to their white peers. Children, with PRC (particularly those with SDB and asthma) are also at risk suggesting that due consideration should be given to these factors in the perioperative care of children undergoing elective surgical procedures. Mechanisms underlying these associations deserve further evaluation.

Rates and Trends of Endotracheal Intubation in Patients With Status Epilepticus.

Among patients with status epilepticus, we sought to determine the rate of endotracheal intubation, identify the physician specialties responsible for endotracheal intubation, and characterize the trend in use of endotracheal intubation over the last 20 years. We performed a cross-sectional study using data from 2 sources. First, we used inpatient claims between 2009 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. Patients with status epilepticus were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, and those who underwent endotracheal intubation were identified based on Current Procedural Terminology codes. Medical specialties of providers performing intubation were identified based on Healthcare Provider Taxonomy Codes. Second, we used claims data from the National Inpatient Sample (NIS) to estimate the annual rates and trends of endotracheal intubation and tracheostomy among patients with status epilepticus from 1995 to 2014. Among 1971 Medicare beneficiaries with status epilepticus, 566 (29%) patients underwent endotracheal intubation. 375 (66%) patients were intubated on admission. The most common medical providers performing intubation in patients with status epilepticus were emergency medicine physicians (50.4%), anesthesiologists (16.4%), and pulmonary medicine physicians (10.1%). Neurologists accounted for 1.7% of all intubations. Among individuals with status epilepticus identified in the NIS, 248 681 (41.7%) were intubated. The proportion of patients intubated increased from 29.5% (95% confidence interval [CI]: 27.8%-31.3%, P = .018) in 1995 to 50.8% (95% CI: 49.6%-52%, P = .012) in 2014. The proportion of patients with status epilepticus who underwent tracheostomy increased from 2.2% (95% CI: 1.7%-2.7%, P = .005) in 1995 to 3.4% (95% CI: 3%-3.9%, P = .004) in 2014. Approximately 1 in 3 patients with status epilepticus undergo endotracheal intubation. Over the last 20 years, the proportion of patients with status epilepticus undergoing endotracheal intubation has almost doubled. Neurologists perform a small percentage of these intubations.

Airway and ventilation management strategies for hemorrhagic shock. To tube, or not to tube, that is the question!

Review article, level IV.

Abstract P-611: TO STUDY THE CLINICAL PROFILE AND OUTCOME OF CHILDREN REQUIRING NONINVASIVE VENTILATION IN PEDIATRIC ICU

Aims & Objectives: Noninvasive ventilation refers to delivery of mechanical respiratory support without the use of endotracheal intubation. Though noninvasive ventilation may have several advantages, there is paucity of literature regarding NIV in critically ill children. This study was done to study the clinical profile of patients requiring NIV and to assess the factors related to outcome. Methods This prospective observational study was done in Pediatric Intensive care unit, DMCH, Ludhiana over a period of one year. This study included all children aged more than one month requiring noninvasive ventilation in Pediatric ICU and data collected was analyzed. Results Total 115 patients with mean age of 81.23 ± 67.97 months, M:F ratio of 1.7:1 were included in the study. Two types of NIV used were BiPAP in 75 (65.2%) and indigenous bubble CPAP in 40 (34.8%) children. Commonest indication of NIV was respiratory distress (77.4%) followed by postextubation (20.9%). Ninety four (81.7%) patients were successfully treated by NIV (NIV success group), 21 (18.3%) failed NIV (NIV failure group). High success rate was seen in primary cardiovascular and respiratory system whereas significantly lower in patients involved sepsis with MODS, abnormal blood gas values (acidosis, hypoventilation and hyperventilation), moderate to severe ARDS. Degree of hypoxemia, inotropes and PRISM score did not affect NIV outcome. Conclusions This study demonstrates the efficacy of NIV as a form of respiratory support for children with acute respiratory failure, preventing further deterioration and avoiding intubation in most of the patients, especially in mild to moderate ARDS, CHF etc.