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Category: Volume 06 Issue 06 June 2018
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Title: Nasal versus oral endotracheal intubation in mechanically ventilated newborn infants in a tertiary care neonatal unit:  a prospective randomized comparative analysis

Authors: K Trimal Subudhi, Bhabagrahi Mallick

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i6.131

Abstract

Backgrounds: Infants in the Neonatal Intensive Care Unit (NICU) are among the highest risk groups for adverse events in the hospital setting. In adult and pediatric intensive care units, adverse events related to endotracheal or tracheostomy tubes comprise a substantial proportion of total adverse events and lead to significant patient harm.

Aim: we planned to conduct this study to compare the advantage and complication associated with nasal versus oral intubation for mechanical ventilation in newborn infants.

Materials and Methods: Intubation was done with a standardized premedication with vecuronium and midazolam except for babies who required emergency intubation. Due to difficulty in procuring the opioids in the unit it was not included in premedication.

Results: the incidence of trauma was found 15.15% of cases in nasal group where as 12.1% in oral group. However this difference between both the groups was statistically not significant (p=1.00).  Only one baby in nasal group had severe septal necrosis where as palatal grooving was found none of oral cases.

Conclusions: Adverse events are common in the NICU, occurring in 4 of 10 intubations. The odds of an adverse event doubled with increasing number of attempts and quadrupled in the emergent setting. Quality improvement efforts to address these factors are needed to improve patient safety

Keywords: patient safety, tracheal intubation, NICU.

References

  1. Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. 2001; 285:2114–2120. 
  2. Snijders C, van Lingen RA, Molendijk A, Fetter WP. Incidents and errors in neonatal intensive care: a review of the literature. Arch Dis Child Fetal Neonatal Ed. 2007;92:F391–F398. 
  3. Needham DM, Thompson DA, Holzmueller CG, Dorman T, Lubomski LH, Wu AW, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS) Crit Care Med. 2004; 32:2227–2233. 
  4. Rivera R, Tibballs J. Complications of endotracheal intubation and mechanical ventilation in infants and children. Crit Care Med. 1992;20:193–199. 
  5. Stambouly JJ, McLaughlin LL, Mandel FS, Boxer RA. Complications of care in a pediatric intensive care unit: a prospective study. Intensive Care Med. 1996;22:1098–1104. 
  6. Skapik JL, Pronovost PJ, Miller MR, Thompson DA, Wu AW. Pediatric safety incidents from an intensive care reporting system. J Patient Saf. 2009;5:95–101. 
  7. Carroll CL, Spinella PC, Corsi JM, Stoltz P, Zucker AR. Emergent endotracheal intubations in children: be careful if it’s late when you intubate. Pediatr Crit Care Med. 2010;11:343–348. 
  8. Nishisaki A, Ferry S, Colborn S, DeFalco C, Dominguez T, Brown CA, 3rd, et al. Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit. Pediatr Crit Care Med. 2012;13:e5–e10. 
  9. Nishisaki A, Turner DA, Brown CA, 3rd, Walls RM, Nadkarni VM, et al. National Emergency Airway Registry for C, A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs. Crit Care Med. 2013;41:874–885. 
  10. Sanders RC, Jr, Giuliano JS, Jr, Sullivan JE, Brown CA, 3rd, Walls RM, Nadkarni V, et al. Level of trainee and tracheal intubation outcomes. 2013; 131:e821–e828. 
  11. Nett S, Emeriaud G, Jarvis JD, Montgomery V, Nadkarni VM, Nishisaki A. Site-Level Variance for Adverse Tracheal Intubation-Associated Events Across 15 North American PICUs: A Report From National Emergency Airway Registry for Children. Pediatr Crit Care Med. 2014;15:306–313. 
  12. Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. 2003;112:1242–1247. 
  13. Lane B, Finer N, Rich W. Duration of intubation attempts during neonatal resuscitation. The Journal of pediatrics. 2004;145(1):67–70. 
  14. Le CN, Garey DM, Leone TA, Goodmar JK, Rich W, Finer NN. Impact of premedication on neonatal intubations by pediatric and neonatal trainees. J Perinatol. 2014;34:458–460. 
  15. Leone TA, Rich W, Finer NN. Neonatal intubation: success of pediatric trainees. J Pediatr. 2005;146(5):638–641. 
  16. O’Donnell CP, Kamlin CO, Davis PG, Morley CJ. Endotracheal intubation attempts during neonatal resuscitation: success rates, duration, and adverse effects. 2006;117:e16–e21. 
  17. Roberts KD, Leone TA, Edwards WH, Rich WD, Finer NN. Premedication for nonemergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium. 2006;118: 1583–1591. 
  18. Foglia EE, Ades A, Napolitano N, Leffelman J, Nadkarni V, Nishisaki A. Factors Associated with Adverse Events during Tracheal Intubation in the NICU. 2015;108:23–29. 
  19. Bancalari E, Sinclair JC. Mechanical ventilation. In: SinclairJC,BrackenMB editor(s). Effective Care of the Newborn Infant. Oxford:Oxford University Press, 1992:210–1.
  20. Roberton NRC. Pulmonary diseases of the newborn. In: Roberton,NRC editor(s). Textbook of Neonatology. Melbourne: Churchill Liv-ingston, 478–9.
  21. Dankle SK, Schuller DE, McClead RE. Prolonged intubation of neonates. Archives ofOtolaryngology--Head&Neck Surgery 1987;113:841–3
  22. Noblett KE, Meibalane R. Respiratory care practitioners as primary providers of neonatal intubation in a community hospital: an analysis.Respiratory Care 1995;40:1063.
  23. Spitzer AR, Fox WW. Postextubation atelectasis - the role of oral versus nasal endotracheal tubes. Journal of Pediatrics 1982;100:806–10.
  24. McMillan DD, Rademaker AW, Buchan KA, Reid A, Machin G, Sauve RS. Benefits of orotracheal and nasotracheal intubation in neonates requiring ventila-tory assistance. Pediatrics 1986;77:39–44
  25. Angelos GM, Smith DR, Jorgenson R, Sweeney EA. Oral complications associated with neonatal oral tracheal intubation: a critical review. Pediatric Dentistry 1989;11:133–40.
  26. Gowdar K, Bull MJ, Schreiner RL, Lemons JA, Gresham EL. Nasal deformities in neonates. American Journal of Diseases of Children1980;134:954–7.
  27. Engle WA: Committee on Fetus and Newborn: Surfactantreplacement therapy for respiratory distress in the preterm and term neonate. Pediatrics 121:419-432, 2008.
  28. Kovacs G, Bullock G, Ackroyd-Stolarz S, et al: A randomized controlled trial on the effect of educational interventions in promoting airway management skill maintenance. Ann Emerg Med 36:301-309, 2000.

Corresponding Author

Dr Bhabagrahi Mallick

Assistant Professor, Department of Paediatrics

IMS and SUM Hospital, Bhubaneswar, India