Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective study

Carine Foz; Steven J Staffa; Raymond Park; ShengXiang Huang; Pete Kovatsis; James Peyton; Meena Nathan; James A DiNardo; Viviane G Nasr

doi:10.1016/j.jclinane.2021.110565

Difficult tracheal intubation and perioperative outcomes in patients with congenital heart disease: A retrospective study

J Clin Anesth. 2022 Feb:76:110565. doi: 10.1016/j.jclinane.2021.110565. Epub 2021 Oct 30.

Authors

Carine Foz¹, Steven J Staffa², Raymond Park², ShengXiang Huang², Pete Kovatsis², James Peyton², Meena Nathan³, James A DiNardo², Viviane G Nasr⁴

Affiliations

¹ Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology and Pain Medicine, American University of Beirut-Medical Center, Beirut, Lebanon.
² Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
³ Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
⁴ Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: viviane.nasr@childrens.harvard.edu.

PMID: 34743956
DOI: 10.1016/j.jclinane.2021.110565

Abstract

Background and objective: Management of difficult tracheal intubation during induction of anesthesia in children with congenital heart disease is challenging. The aim of this study is to evaluate the incidence of difficult tracheal intubation in patients with congenital heart disease and compare the incidence of perioperative complications and outcomes in patients with and without difficult tracheal intubation.

Design: Retrospective cohort study.

Setting: Tertiary Children's Hospital.

Participants: 6858 patient-encounters including cardiac diagnostic, interventional or surgical procedures from 2012 to 2018 were reviewed.

Exclusion criteria: age > 18 years, endotracheal tube or tracheostomy in-situ.

Methods/interventions: Patients' demographics, number and methods of intubation, peri-intubation hemodynamics, intensive care unit and postoperative hospital length of stay were recorded. Multivariable mixed-effects median, logistic, ordinal, and multinomial regression modeling were implemented to analyze outcomes in the matched sets.

Results: Of the 6014 encounters examined in the study, the incidence of DTI was 0.96% and all 58 difficult tracheal intubations (DTI) were matched using 1:2 propensity score matching to 116 non-DTI encounters. Number of intubation attempts was significantly higher among patients with difficult tracheal intubation (ordinal logistic regression odds ratio = 2; 95% CI; 1.3, 2.7; P < 0.001). No significant differences in peri-intubation hemodynamic stability were noted. Patients with difficult tracheal intubation had longer postoperative hospital length of stay (median = 12.1 vs 7.9 days, coef. = 4; 95% CI: 1.3, 6.8; P = 0.004) than patients without.

Conclusion: Despite a higher number of intubation attempts, our study shows no major differences in the peri-intubation hemodynamics in patients with and without difficult tracheal intubation. This risk can be mitigated by a good understanding of cardiac physiology, management of hemodynamics, and early use of an indirect intubation technique to maximize first attempt success.

Keywords: Children; Congenital heart disease; Difficult tracheal intubation.

MeSH terms

Adult
Child
Heart Defects, Congenital* / surgery
Humans
Incidence
Intubation, Intratracheal* / adverse effects
Intubation, Intratracheal* / methods
Middle Aged
Propensity Score
Retrospective Studies