J Arden Conway1, Priyanka Kharayat2, Ronald C Sanders1, Sholeen Nett3, Scott L Weiss4, Lauren R Edwards1, Ryan Breuer5, Aileen Kirby6, Conrad Krawiec7, Christopher Page-Goertz8, Lee Polikoff9, David A Turner10, Justine Shults11, John S Giuliano12, Alberto Orioles13, Sylvain Balkandier14, Guillaume Emeriaud14, Kyle J Rehder10, Joel Lim Kian Boon15, Asha Shenoi16, Paula Vanderford6, Gabrielle Nuthall17, Anthony Lee18, Jonida Zeqo19, Simon J Parsons20, Jamie Furlong-Dillard21, Keith Meyer22, Ilana Harwayne-Gidansky23, Philipp Jung24, Michelle Adu-Darko25, G Kris Bysani26, Melissa A McCarthy27, Mark Shlomovich28, Iris Toedt-Pingel29, Aline Branca30, Maria Christina Esperanza31, Awni M Al-Subu32, Matthew Pinto33, Sarah Tallent34, Rakshay Shetty35, Sujatha Thyagarajan35, Takanari Ikeyama36, Keiko M Tarquinio37, Peter Skippen38, Mioko Kasagi39, Joy D Howell40, Vinay M Nadkarni2,41, Akira Nishisaki2,41. 1. Section of Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR. 2. Center for Simulation, Advanced Education and Innovation, Children's Hospital of Philadelphia, Philadelphia, PA. 3. Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH. 4. Department of Anesthesiology and Critical Care and the Pediatric Sepsis Program at the Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. 5. Division of Pediatric Critical Care Medicine, Oishei Children's Hospital, Buffalo, NY. 6. Division of Pediatric Critical Care Medicine, Doernbecher Children's Hospital, Portland, OR. 7. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children's Hospital, Pennsylvania State University College of Medicine, Hershey, PA. 8. Department of Pediatric Critical Care Medicine, Akron Children's Hospital, Akron, OH. 9. Division of Pediatric Critical Care Medicine, The Warren Alpert School of Medicine at Brown University, Providence, RI. 10. Division of Pediatric Critical Care, Department of Pediatrics, Duke Children's Hospital, Durham, NC. 11. Department of Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 12. Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT. 13. Division of Critical Care, Children's Hospital and Clinics of Minnesota, Minneapolis, MN. 14. Department of Pediatrics, Sainte-Justine University Hospital Center, Montreal, QC, Canada. 15. Department of Paediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore. 16. Division of Pediatric Critical Care, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky School of Medicine, Lexington, KY. 17. Department of Paediatrics Child and Youth Health, Paediatric Intensive Care Unit, Starship Hospital, Auckland, New Zealand. 18. Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University, Columbus, OH. 19. Department of Pediatric Anesthesiology, Arkansas Children's Hospital, Little Rock, AR. 20. Section of Critical Care, Department of Pediatrics, Alberta Children's Hospital, Calgary, AB, Canada. 21. Division of Pediatric Critical Care, University of Louisville and Norton Children's Hospital, Louisville, KY. 22. Division of Critical Care Medicine, Nicklaus Childrens Hospital, Miami, FL. 23. Division of Critical Care, Stony Brook Children's Hospital, Stony Brook, NY. 24. Department of Pediatrics, University Hospital Schleswing-Holstein, Campus Lübeck, Lübeck, Germany. 25. Division of Critical Care, Children's Hospital of the University of Virginia, Charlottesville, VA. 26. Pediatric Critical Care Medicine, Pediatric Acute Care Associates of North Texas PLLC, Medicine, Medical City Children's Hospital, Dallas, TX. 27. Department of Critical Care Medicine, Children's Hospital of Pittsburgh at University of Pittsburgh Medical Center, Pittsburgh, PA. 28. Department of Pediatric Critical Care Medicine, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY. 29. Division of Pediatric Critical Care, Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT. 30. Pediatric Critical Care Medicine, Department of Pediatrics, Phoenix Children's Hospital, Phoenix, AZ. 31. Pediatric Critical Care Medicine, Department of Pediatrics, Steven & Alexandra Cohen Children's Hospital, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY. 32. Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI. 33. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Maria Fareri Children's Hospital, Valhalla, NY. 34. Division of Pediatric and Congenital Heart Center, Department of Pediatric Critical Care Medicine, Duke University Hospital, Durham, NC. 35. Division of Critical Care, Rainbow Children's Hospital, Marathahalli, Bangalore, India. 36. Division of Pediatric Critical Care Medicine, Aichi Children's Health and Medical Center, Aichi, Japan. 37. Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA. 38. Intensive Care Unit, Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada. 39. Department of Pediatric Critical Care & Emergency Medicine, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. 40. Department of Pediatrics, New York-Presbyterian Weill Cornell Medican Center, New York, NY. 41. Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA.
Abstract
OBJECTIVES: Tracheal intubation in critically ill children with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically ill children with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. DESIGN: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. SETTING: Forty international PICUs participating in the National Emergency Airway Registry for Children. PATIENTS: Critically ill children 0-17 years old who underwent tracheal intubation in a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. CONCLUSIONS: Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.
OBJECTIVES: Tracheal intubation in critically illchildren with shock poses a risk of hemodynamic compromise. Ketamine has been considered the drug of choice for induction in these patients, but limited data exist. We investigated whether the administration of ketamine for tracheal intubation in critically illchildren with or without shock was associated with fewer adverse hemodynamic events compared with other induction agents. We also investigated if there was a dose dependence for any association between ketamine use and adverse hemodynamic events. DESIGN: We performed a retrospective analysis using prospectively collected observational data from the National Emergency Airway Registry for Children database from 2013 to 2017. SETTING: Forty international PICUs participating in the National Emergency Airway Registry for Children. PATIENTS: Critically illchildren 0-17 years old who underwent tracheal intubation in a PICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The association between ketamine exposure as an induction agent and the occurrence of adverse hemodynamic events during tracheal intubation including dysrhythmia, hypotension, and cardiac arrest was evaluated. We used multivariable logistic regression to account for patient, provider, and practice factors with robust SEs to account for clustering by sites. Of 10,750 tracheal intubations, 32.0% (n = 3,436) included ketamine as an induction agent. The most common diagnoses associated with ketamine use were sepsis and/or shock (49.7%). After adjusting for potential confounders and sites, ketamine use was associated with fewer hemodynamic tracheal intubation associated adverse events compared with other agents (adjusted odds ratio, 0.74; 95% CI, 0.58-0.95). The interaction term between ketamine use and indication for shock was not significant (p = 0.11), indicating ketamine effect to prevent hemodynamic adverse events is consistent in children with or without shock. CONCLUSIONS:Ketamine use for tracheal intubation is associated with fewer hemodynamic tracheal intubation-associated adverse events.
Authors: Garrett S Pacheco; Nicholas B Hurst; Asad E Patanwala; Cameron Hypes; Jarrod M Mosier; John C Sakles Journal: West J Emerg Med Date: 2021-02-01