: A Single-center, Retrospective Study,
Jorge A. Gálvez, M.D., M.B.I.; Samuel Acquah, M.D.; Luis Ahumada, Ph.D.; Lingyu Cai, M.S.; Marcia Polanski, S.C.D, M.S., M.S.W.; et al Lezhou Wu, Ph.D.; Allan F. Simpao, M.D., M.B.I.; Jonathan M. Tan, M.D., M.P.H.; Jack Wasey, B.M., B.Ch., M.A., M.Sci., M.Sc.; John E. Fiadjoe, M.D.
Author Notes
From the Section of Biomedical Informatics (J.A.G., L.A., L.W., A.F.S., J.M.T., J.W.), Department of Anesthesia and Critical Care Medicine (J.A.G., A.F.S., J.M.T., J.W., J.E.F.), Enterprise Reporting and Analytics (L.A., L.W.), The Children’s Hospital of Philadelphia (J.A.G., L.A., L.W., A.F.S., J.M.T., J.W., J.E.F.); the University of Pennsylvania Perelman School of Medicine (J.A.G, S.A., A.F.S., J.M.T., J.W., J.E.F.); and Drexel University, Dornsife School of Public Health (L.C., M.P.), Philadelphia, Pennsylvania.
Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
The work presented in this article has been presented at the Section of Biomedical Informatics Research meeting in the Department of Anesthesiology and Critical Care Medicine at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, May 16, 2017. The preliminary data set for this article has been presented as a scholarly pursuit project by Dr. Acquah for the completion of his medical education at the Perelman University School of Medicine, Philadelphia, Pennsylvania, May 2017. The preliminary data set for this article has been presented in a grant application for the Anesthesia Patient Safety Foundation (Rochester, Minneapolis) grant in 2017. The Anesthesia Patient Safety Foundation awarded a grant to Dr. Fiadjoe to conduct the Videolaryngoscopy in Small Infants (VISI) Trial. The grant funding was not used to conduct the research presented in this manuscript.
Submitted for publication October 22, 2018. Accepted for publication May 6, 2019.
Correspondence: Address correspondence to Dr. Gálvez: Section of Biomedical Informatics, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd., Suite 9329, Philadelphia, Pennsylvania 19104. galvezj@email.chop.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Anesthesiology Newly Published on July 10, 2019. doi:10.1097/ALN.0000000000002847
What We Already Know about This Topic:
Successful tracheal intubation of an infant may be a challenging skill to acquire due to differing anatomy and physiology compared to older children and adults
Multiple intubation attempts may be associated with increased complications
What This Article Tells Us That Is New:
In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies
There was also a 35% incidence of hypoxemia, defined as an oxygen saturation measurement less than 90%, during induction of anesthesia
There was evidence for an association between multiple laryngoscopies and hypoxemia
Background: The infant airway is particularly vulnerable to trauma from repeated laryngoscopy attempts. Complications associated with elective tracheal intubations in anesthetized infants may be underappreciated. We conducted this study of anesthetized infants to determine the incidence of multiple laryngoscopy attempts during routine tracheal intubation and assess the association of laryngoscopy attempts with hypoxemia and bradycardia.
Methods: We conducted a retrospective cross-sectional cohort study of anesthetized infants (age less than or equal to 12 months) who underwent direct laryngoscopy for oral endotracheal intubation between January 24, 2015, and August 1, 2016. We excluded patients with a history of difficult intubation and emergency procedures. Our primary outcome was the incidence of hypoxemia or bradycardia during induction of anesthesia. We evaluated the relationship between laryngoscopy attempts and our primary outcome, adjusting for age, weight, American Society of Anesthesiologists status, staffing model, and encounter location.
Results: A total of 1,341 patients met our inclusion criteria, and 16% (n = 208) had multiple laryngoscopy attempts. The incidence of hypoxemia was 35% (n = 469) and bradycardia was 8.9% (n = 119). Hypoxemia and bradycardia occurred in 3.7% (n = 50) of patients. Multiple laryngoscopy attempts were associated with an increased risk of hypoxemia (adjusted odds ratio: 1.78, 95% CI: 1.30 to 2.43, P < 0.001). There was no association between multiple laryngoscopy attempts and bradycardia (adjusted odds ratio: 1.23, 95% CI: 0.74 to 2.03, P = 0.255).
Conclusions: In a quaternary academic center, healthy infants undergoing routine tracheal intubations had a high incidence of multiple laryngoscopy attempts and associated hypoxemia episodes.
Jorge A. Gálvez, M.D., M.B.I.; Samuel Acquah, M.D.; Luis Ahumada, Ph.D.; Lingyu Cai, M.S.; Marcia Polanski, S.C.D, M.S., M.S.W.; et al Lezhou Wu, Ph.D.; Allan F. Simpao, M.D., M.B.I.; Jonathan M. Tan, M.D., M.P.H.; Jack Wasey, B.M., B.Ch., M.A., M.Sci., M.Sc.; John E. Fiadjoe, M.D.
Author Notes
From the Section of Biomedical Informatics (J.A.G., L.A., L.W., A.F.S., J.M.T., J.W.), Department of Anesthesia and Critical Care Medicine (J.A.G., A.F.S., J.M.T., J.W., J.E.F.), Enterprise Reporting and Analytics (L.A., L.W.), The Children’s Hospital of Philadelphia (J.A.G., L.A., L.W., A.F.S., J.M.T., J.W., J.E.F.); the University of Pennsylvania Perelman School of Medicine (J.A.G, S.A., A.F.S., J.M.T., J.W., J.E.F.); and Drexel University, Dornsife School of Public Health (L.C., M.P.), Philadelphia, Pennsylvania.
Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
The work presented in this article has been presented at the Section of Biomedical Informatics Research meeting in the Department of Anesthesiology and Critical Care Medicine at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, May 16, 2017. The preliminary data set for this article has been presented as a scholarly pursuit project by Dr. Acquah for the completion of his medical education at the Perelman University School of Medicine, Philadelphia, Pennsylvania, May 2017. The preliminary data set for this article has been presented in a grant application for the Anesthesia Patient Safety Foundation (Rochester, Minneapolis) grant in 2017. The Anesthesia Patient Safety Foundation awarded a grant to Dr. Fiadjoe to conduct the Videolaryngoscopy in Small Infants (VISI) Trial. The grant funding was not used to conduct the research presented in this manuscript.
Submitted for publication October 22, 2018. Accepted for publication May 6, 2019.
Correspondence: Address correspondence to Dr. Gálvez: Section of Biomedical Informatics, Department of Anesthesiology and Critical Care Medicine, 3401 Civic Center Blvd., Suite 9329, Philadelphia, Pennsylvania 19104. galvezj@email.chop.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Anesthesiology Newly Published on July 10, 2019. doi:10.1097/ALN.0000000000002847
What We Already Know about This Topic:
Successful tracheal intubation of an infant may be a challenging skill to acquire due to differing anatomy and physiology compared to older children and adults
Multiple intubation attempts may be associated with increased complications
What This Article Tells Us That Is New:
In a quaternary pediatric academic center, 16% of healthy infants undergoing routine tracheal intubations had multiple laryngoscopies
There was also a 35% incidence of hypoxemia, defined as an oxygen saturation measurement less than 90%, during induction of anesthesia
There was evidence for an association between multiple laryngoscopies and hypoxemia
Background: The infant airway is particularly vulnerable to trauma from repeated laryngoscopy attempts. Complications associated with elective tracheal intubations in anesthetized infants may be underappreciated. We conducted this study of anesthetized infants to determine the incidence of multiple laryngoscopy attempts during routine tracheal intubation and assess the association of laryngoscopy attempts with hypoxemia and bradycardia.
Methods: We conducted a retrospective cross-sectional cohort study of anesthetized infants (age less than or equal to 12 months) who underwent direct laryngoscopy for oral endotracheal intubation between January 24, 2015, and August 1, 2016. We excluded patients with a history of difficult intubation and emergency procedures. Our primary outcome was the incidence of hypoxemia or bradycardia during induction of anesthesia. We evaluated the relationship between laryngoscopy attempts and our primary outcome, adjusting for age, weight, American Society of Anesthesiologists status, staffing model, and encounter location.
Results: A total of 1,341 patients met our inclusion criteria, and 16% (n = 208) had multiple laryngoscopy attempts. The incidence of hypoxemia was 35% (n = 469) and bradycardia was 8.9% (n = 119). Hypoxemia and bradycardia occurred in 3.7% (n = 50) of patients. Multiple laryngoscopy attempts were associated with an increased risk of hypoxemia (adjusted odds ratio: 1.78, 95% CI: 1.30 to 2.43, P < 0.001). There was no association between multiple laryngoscopy attempts and bradycardia (adjusted odds ratio: 1.23, 95% CI: 0.74 to 2.03, P = 0.255).
Conclusions: In a quaternary academic center, healthy infants undergoing routine tracheal intubations had a high incidence of multiple laryngoscopy attempts and associated hypoxemia episodes.
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