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Peter Juviler, MD - Best of the Best in Pediatric Surgery 2024
With Dr. Peter Juviler · hosted by Dr. Todd Ponsky
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Postoperative unplanned intubation is associated with mortality in pediatric patients with neonate status identified as an independent risk factor.
In 2017 and 2018, the children's hospital was identified as a negative outlier in NICO pediatric for unplanned intubation events.
Greater than 85% of unplanned intubation events were seen in children less than 1 year old.
The project took place at a 68 bed NICU within a Quaternary academic Center.
The smart aim was to reduce post-op unplanned intubation events in the NICU by 25% in one year.
The pain guideline consisted of minimizing opioids and opioid infusions and prescribing all patients acetaminophen for 48 to 72 hours post-op.
The 10 item extubation checklist had no individual requirement for yes or no response and was completed and signed as part of the medical record.
Following intervention, NICU unplanned intubation decreased, resulting in a 76% reduction in events.
Morphine equivalent decreased from 39.5 to 7.9 following intervention.
Patients receiving opioids decreased from 85 to 51% following intervention.
Patients receiving opioid infusion decreased from 65 to 21% following intervention.
Post-op acetaminophen prescription increased from 25 to 90% following intervention.
The average proportion of postoperative unplanned intubation events decreased from 0.27 to 0.07 events per patient, which equates to 11 fewer unplanned intubation events per year.
Checklist adherence reached the team's goal of 80%.
There was no difference in balancing measures, including hospital length of stay and pneumonia rate.
Mortality decreased from 6.5 to 0.7% following intervention.
The project team had a pediatric surgeon leading it, with multiple representatives from the NICU, ENT and anesthesia as well as nursing and medical students.
2 of 13 mortalities experienced an unplanned intubation event pre-intervention versus 0 of 1 post-intervention.
To our knowledge, no attempt to reduce these events has been described in the pediatric population.
The working group met at least monthly over the course of the project.
The ET tube actually falling out prematurely was a relatively small proportion of what was found to be driving the unplanned intubation.
Patients maybe a day or two later after they were chosen to be extubated on purpose then required reintubation, and this was thought to have a lot to do with sedation.
There has been a massive reduction in opioid use in teenagers after elective surgery, and no one even really uses them anymore.