Investigators from multiple institutions conducted a retrospective study to assess the frequency of peri-intubation cardiac arrest (PICA) in critically ill children <18 years old with cardiac conditions to identify risk factors for PICA. Study participants were patients admitted to standalone pediatric cardiac ICUs between 2015 and 2017 who required emergent endotracheal intubation. Multiple intubations on the same patient were included in the analyses. PICA was defined as any form of cardiac arrest requiring chest compressions for ≥1 minute that occurred within 30 minutes of intubation. Data collected on study participants included demographics, cardiac history, event characteristics, and outcomes. Cardiac conditions and clinical and event characteristics in those with or without cardiac arrest were compared using chi-square and t-tests to identify risk factors for PICA; the unit of analysis for these comparisons was intubations.
Data were analyzed on 186 intubations on a total of 151 patients. The median age of study participants was 3.1 months (interquartile range 0.33 to 21.8 months); 47 of 149 (31.5%) children were born between 30 and 36 weeks’ gestation, and 3 (2%) were born at ≤29 weeks’ gestation. Among the intubations, 45 (24.2%) were performed on patients with a single ventricle, 74 (39.8%) occurred within 30 days of cardiac surgery, and 13 (6.9%) were in children with trisomy 21. Overall, PICA occurred after 13 of the 186 intubations (7%). Following these cardiac arrests, return of spontaneous circulation was restored in 7 (53.8%), circulation was restored with extracorporeal membrane oxygenation (ECMO) in 3 (23.1%), and 3 children died (23.1% of PICA events). Overall, the peri-intubation mortality was 1.6% (3 of 186 intubations). Suspected etiologies of PICA included prolonged hypoxia in 5 cases (38.5%), worsened acidosis in 5 (38.5%), medication-induced bradycardia in 3 (23.1%), and misplaced endotracheal tube in 2 (15.4%). Median duration of CPR was 10 minutes following PICA. Compared to intubations that did not lead to cardiac arrest, PICA was more common in patients with documented hypotension, defined as a decrease of mean arterial pressure ≥20% from baseline (18.4% and 60%, respectively, P = .007). Moderate to severe dysfunction of the systemic ventricle was reported on the most recent echocardiogram prior to intubation in 23% of PICA events compared to 8.5% of intubations without cardiac arrest (P = .048). Increased lactate levels and decreased pH also were associated significantly with an increased risk of PICA.
The authors conclude that critically ill pediatric patients with cardiac disease are at risk for PICA.
Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
The current authors report that PICA occurred in 7% of critically ill children with cardiac disease, of whom 23% died. Measures of poor perfusion (hypotension, elevated...