2005 OPEN FORUM Abstracts
NEAR-4-KIDS: ADAPTATION OF THE NEAR (National Emergency Airway Registry) TOOL FOR A PEDIATRIC INTENSIVE CARE UNIT (PICU)
Lisa Tyler, BS, RRT-NPS, CPFT, Gim Tan, MD, Cheryl DeFalco, RRT-NPS, Troy Dominguez, MD, Ron Walls, MD, Vinay Nadkarni, MD for the NEAR investigators. The Children's Hospital of Philadelphia. Philadelphia, Pennsylvania and Brigham and Women's Hospital, Boston, MA
Background: Tracheal intubation is a routine procedure in the PICU, but indications, personnel, techniques, success rates, difficult airway evaluation, complications and rescue procedures have not been systematically reported. The multi-center National Emergency Airway Registry project (NEAR)1, has recently characterized airway management of adult and pediatric emergency department patients. Purpose: To evaluate a modified NEAR data management system to characterize tracheal intubation practices in the PICU. Methods: The paper version of the NEAR web-based data entry tool was adapted by multidisciplinary consensus of PICU practitioners for application to critically ill children. With IRB approval, a prospective, observational study was conducted for 6 months in a 45-bed PICU. Patient and practitioner data include indication, confirmation technique, difficult airway evaluation, intubation events (including complications,) rescue procedures, intubation success, and comments. Practitioners were asked to complete the form immediately following intubation. Data capture was confirmed by secondary follow-up within 24 hours, with an interim analysis and iterative data form modification at three months.
Results: A total of 99 tracheal intubations were characterized: 67 initial orotracheal and 32 conversions of orotracheal to nasotracheal. 100% intubation capture was achieved by a combination of voluntary practitioner form completion at the time of intubation with respiratory therapist follow-up (80%), and 24 hour follow up screen of all mechanically ventilated patients with e-mail reminder (20%). Indications were documented in 97%, most commonly oxygenation failure (57%). Tracheal placement was confirmed by breath sounds in 98%, chest rise in 92%, exhaled CO2 in 98%, X-ray in 80%, and undocumented in 2%. The modified data form called for pre-intubation assessment of five difficult airway attributes. Evaluation of any attribute was documented in 98%: 20% had difficult intubation noted by history and 35% by physical exam. There was 15% compliance with pre-intubation performance of the Mallampati score in 15 consecutive intubations, thus this maneuver was removed from the scoring tool. Complete formal difficult airway evaluation was documented in only 32%. Intubation events (e.g. esophageal intubation, pneumothorax, hypotension, cardiac arrest) were documented in 20/67 (30%) initial intubations; there were no events in 25% and undocumented in 45%. Rescue procedures (tracheostomy or transport to OR) were documented in 2/67 (3%).
Conclusions: The NEAR registry tool can be adapted for children in PICUs. Data capture is incomplete by voluntary practitioner form completion at the time of intubation, and an aggressive screening and follow-up system is essential. Special attention is required for complete formal difficult airway assessments, which are completed less than 33% of the time, but there is high compliance with indications, confirmation, events (complications,) and rescue procedures using the modified NEAR-4-KIDS tool. 1 www.near.edu/index.cfm Supported by the Endowed Chair of Critical Care Medicine: CHOP