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Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
Intensive medical care for critically ill children is a relatively recent development that can only be afforded by rich countries. Even the large units take less than 1,500 patients a year with an average mortality of about 5%. Most of the survivors have a very good quality of life. In global terms, this does not even scratch the surface; UNICEF's last estimate for 1994 was 12.5 million avoidable deaths of children < 5 years of age. Most of these children simply required food, clean water and immunization. Community medicine cannot match the Intensive Care Unit (ICU) for drama and fascinating gadgets that go beep, but the principles of primary health care have saved millions more lives than all the ICU's together will ever achieve.
Pediatric intensive care is still a new discipline. It borrows from the slightly older literature of adult and neonatal intensive care, and there is a growing body of relevant research. However, many clinical decisions are still made on the basis of little more than common sense. Consequently, a detailed knowledge of pathophysiology is vital for any physician working with critically ill children.
Care of critically ill children is frequently very rewarding; many of the children recover well because they are usually free of underlying chronic illness. It must be stressed, however, that changes in clinical condition happen very quickly and require an appropriately prompt response from the attending physician to avert a disaster.
The following chapter will focus on the four areas that keep the ICU full: cardiac disease, respiratory disease, central nervous system disease and major trauma.
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