Matthew Malone, MD,
Assistant Professor of Pediatrics
University of Arkansas for Medical Sciences Arkansas Childrens Hospital
Little Rock, United States
Disclosure information not submitted.
Ilana Harwayne-Gidansky, MA, MD (she/her/hers)
Associate Professor of Pediatrics
Bernard and Millie Duker Children's Hospital at Albany Medical Center
Albany, NY
Disclosure information not submitted.
Jennifer Pham, MD
Assistant Professor of Pediatrics
Sunrise Hospital and Medical Center, United States
Disclosure information not submitted.
Lee Polikoff, MD (he/him/his)
Hasbro Children's Hospital
Providence, Rhode Island
Disclosure information not submitted.
Melinda Register, RRT
Respiratory Therapist
Childrens Healthcare of Atlanta, United States
Disclosure information not submitted.
Keiko Tarquinio, MD
Assistant Professor of Pediatrics
Emory University Department of Pediatrics, United States
Disclosure information not submitted.
Ronald Sanders, MD, MS, FCCM
Professor of Pediatrics
Arkansas Childrens Hospital, United States
Disclosure information not submitted.
Natalie Napolitano, MPH, MPH, RRT-NPS (she/her/hers)
Research Clinical Specialist
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
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Justine Shults, PhD
Professor of Biostatistics
Perelman School of Medicine, United States
Disclosure information not submitted.
.jpg "Vinay Nadkarni, MD, MS, FCCM (he/him/his) photo")
Vinay Nadkarni, MD, MS, FCCM (he/him/his)
Professor, Anesthesiology, Critical Care and Pediatrics
University of Pennsylvania Perelman School of Medicine, CHOP
Media, Pennsylvania, United States
Disclosure information not submitted.
Akira Nishisaki, MD, MSCE
Associate Professor of Anesthesia and Critical Care Medicine
The Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: Tracheal Re-Intubation After Unplanned Extubation: Is There a Higher Risk?
Introduction/Hypothesis: Unplanned extubation (UE) in the Pediatric ICU has been recognized as a preventable harm, yet the magnitude of its consequences is not well described. The National Emergency Airway Registry for Children (NEAR4KIDS) is a collaborative quality improvement initiative aimed to improve tracheal intubation (TI) success and prevent adverse events with airway manipulation. We hypothesized that TI after UE is associated with a higher risk for adverse airway outcomes (AAO), including peri-intubation hypoxemia.
Methods: The NEAR4KIDS database was queried for all ICU TIs in patients 0-18 years of age between 2014-2020. AAO was defined as any adverse TI associated event and/or peri-intubation hypoxemia (SpO2 < 80%). UE trends over years were calculated by chi2 for non-parametric trends. Multivariable logistic regression was used to evaluate the association between UE and AAO, while controlling for confounders.
Results: Out of 23,320 TIs from 59 ICUs, UE was reported as an indication for TI in 373 (1.6%). The proportion of UE as an indication increased over time, 0.1% in year 2014 to 2.8% in year 2020 (p < 0.001). TIs after UE compared to TIs without UE were more commonly in infants (62% vs. 48%, p < 0.001), males (63% vs. 56%, p=0.003), and in children with a history of difficult airway (17% vs.13%, p=0.03). TI after UE utilized video laryngoscope more often (42% vs.33%, p=0.004), and apneic oxygenation less often (16% vs. 18%, p=0.25). There was no difference in AAO (UE: 23.9% vs. non-UE 24.6%, p=0.81), in TI associated events (UE: 12.3% vs. non-UE 13.1%, p=0.76), or in hypoxemia (UE: 16.9% vs. non-UE 16.0%, p=0.62). After controlling for potential confounders (age, sex, indication, difficult airway, device, apneic oxygenation, neuromuscular blockade use, and intubation year), TI after UE was not associated with AAO (aOR 1.23 95% CI 0.96-1.57, p=0.095). However, TI after UE was significantly associated with peri-intubation hypoxemia (aOR 1.33, 95% CI 1.01-1.76, p=0.044).
Conclusions: UE is increasingly reported as an indication for TI in the PICU. Interestingly, TI after UE was not associated with adverse airway outcomes (AAO), but was associated with increased peri-intubation hypoxemia after controlling for confounders.