Hemodynamic Impact of Oxygen Desaturation during Tracheal Intubation among Critically Ill Children with Cyanotic and Noncyanotic Heart Disease∗

Objectives: To determine a level of oxygen desaturation from baseline that is associated with increased risk of tracheal intubation associated events in children with cyanotic and noncyanotic heart disease. Design: Retrospective analysis of prospectively collected data from the National Emergency Airway Registry for Children, an international multicenter quality improvement collaborative for airway management in critically ill children. Setting: Thirty-eight PICUs from July 2012 to December 2016. Patients: Children with cyanotic and noncyanotic heart disease who underwent tracheal intubation in a pediatric or cardiac ICU. Interventions: None. Measurements and Main Results: Our exposure of interest was oxygen desaturation measured by a fall in pulse oximetry from baseline after preoxygenation. Primary outcome was the occurrence of hemodynamic tracheal intubation associated events defined as cardiac arrest, hypotension or dysrhythmia. One-thousand nine-hundred ten children (cyanotic, 999; noncyanotic, 911) were included. Patients with cyanotic heart disease who underwent tracheal intubations were younger (p < 0.001) with higher Pediatric Index of Mortality 2 scores (p < 0.001), more likely to have a cardiac surgical diagnosis (p < 0.001), and less likely to have hemodynamic instability (p = 0.009) or neurologic failure as an indication (p = 0.008). Oxygen desaturation was observed more often in children with cyanotic versus noncyanotic heart disease (desaturation of 15% to < 30%: 23% vs 16%, desaturation ≥ 30%: 23% vs 17%; p < 0.001), with no significant difference in occurrence of hemodynamic tracheal intubation associated events (7.5% vs 6.9%; p = 0.618). After adjusting for confounders, oxygen desaturation by 30% or more is associated with increased odds for adverse hemodynamic events (odds ratio, 4.03; 95% CI, 2.12-7.67) for children with cyanotic heart disease and (odds ratio, 3.80; 95% CI, 1.96-7.37) for children with noncyanotic heart disease. Conclusions: Oxygen desaturation was more commonly observed during tracheal intubation in children with cyanotic versus noncyanotic heart disease. However, hemodynamic tracheal intubation associated event rates were similar. In both groups, oxygen desaturation greater than or equal to 30% was significantly associated with increased occurrence of hemodynamic tracheal intubation associated events.