一项前瞻性多中心观察性队列研究的当前用药实践与气管插管安全结局

Current medication practice and tracheal intubation safety outcomes from a prospective multicenter observational cohort study.

作者信息

Tarquinio Keiko M, Howell Joy D, Montgomery Vicki, Turner David A, Hsing Deyin D, Parker Margaret M, Brown Calvin A, Walls Ron M, Nadkarni Vinay M, Nishisaki Akira

机构信息

1Department of Pediatrics, Pediatric Critical Care Medicine, Hasbro Children's Hospital, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI. 2Department of Pediatrics, Weill Cornell Medical College, New York, NY. 3Pediatric Critical Care Medicine, University of Louisville, Louisville, KY. 4Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Duke University Medical Center, Durham, NC. 5Department of Pediatrics, Pediatric Critical Care Medicine, Stony Brook University School of Medicine, Stony Brook, NY. 6Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. 7Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA.

出版信息

Pediatr Crit Care Med. 2015 Mar;16(3):210-8. doi: 10.1097/PCC.0000000000000319.

DOI:10.1097/PCC.0000000000000319

PMID:25581629

Abstract

OBJECTIVES

Tracheal intubation in PICUs is often associated with adverse tracheal intubation-associated events. There is a paucity of data regarding medication selection for safe tracheal intubations in PICUs. Our primary objective was to evaluate the association of medication selection on specific tracheal intubation-associated events across PICUs.

DESIGN

Prospective observational cohort study.

SETTING

Nineteen PICUs in North America.

SUBJECTS

Critically ill children requiring tracheal intubation.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Using the National Emergency Airway Registry for Children, tracheal intubation quality improvement data were prospectively collected from July 2010 to March 2013. Patient, provider, and practice characteristics including medications and dosages were collected. Adverse tracheal intubation-associated events were defined a priori. A total of 3,366 primary tracheal intubations were reported. Adverse tracheal intubation-associated events occurred in 593 tracheal intubations (18%). Fentanyl and midazolam were the most commonly used induction medications (64% and 58%, respectively). Neuromuscular blockade was used in 92% of tracheal intubation with the majority using rocuronium (64%) followed by vecuronium (20%). Etomidate and succinylcholine were rarely used (1.6% and 0.7%, respectively). Vagolytics were administered in 37% of tracheal intubations (51% in infants; 28% in > 1 yr old; p < 0.001). Ketamine was used in 27% of tracheal intubations but more often for tracheal intubations in patients with unstable hemodynamics (39% vs 25%; p < 0.001). However, ketamine use was not associated with lower prevalence of new hypotension (ketamine 8% vs no ketamine 14%; p = 0.08).

CONCLUSIONS

In this large, pediatric multicenter registry, fentanyl, midazolam, and ketamine were the most commonly used induction agents, and the majority of tracheal intubations involved neuromuscular blockade. Ketamine use was not associated with lower prevalence of hypotension.

摘要

目的

儿科重症监护病房（PICU）的气管插管常伴有不良的气管插管相关事件。关于PICU中安全气管插管药物选择的数据匮乏。我们的主要目的是评估药物选择与PICU中特定气管插管相关事件之间的关联。

设计

前瞻性观察队列研究。

地点

北美的19个PICU。

研究对象

需要气管插管的危重症儿童。

干预措施

无。

测量与主要结果

利用国家儿童紧急气道注册系统，前瞻性收集了2010年7月至2013年3月的气管插管质量改进数据。收集了患者、医护人员和实践特征，包括药物和剂量。预先定义了不良气管插管相关事件。共报告了3366例初次气管插管。593例气管插管（18%）发生了不良气管插管相关事件。芬太尼和咪达唑仑是最常用的诱导药物（分别为64%和58%）。92%的气管插管使用了神经肌肉阻滞剂，其中大多数使用罗库溴铵（64%），其次是维库溴铵（20%）。依托咪酯和琥珀酰胆碱很少使用（分别为1.6%和0.7%）。37%的气管插管使用了抗迷走神经药（婴儿中为51%；1岁以上儿童中为28%；p<0.001）。27%的气管插管使用了氯胺酮，但在血流动力学不稳定的患者中气管插管时使用更频繁（39%对25%；p<0.001）。然而，使用氯胺酮与新发低血压的发生率较低无关（氯胺酮组为8%，未使用氯胺酮组为14%；p=0.08）。