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Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia.

Jones P, Peters MJ, Pinto da Costa N, Kurth T, Alberti C, Kessous K, Lode N, Dauger S - PLoS ONE (2013)

Bottom Line: The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19-0.95, p=0.04).Atropine use during induction was associated with a reduction in ICU mortality in children over one month.This result needs to be confirmed in a study using randomised methodology.

View Article: PubMed Central - PubMed

Affiliation: Critical Care Group - Portex Unit, Institute of Child Health, University College London, London, Great Britain.

ABSTRACT

Background: Atropine has is currently recommended to facilitate haemodynamic stability during critical care intubation. Our objective was to determine whether atropine use at induction influences ICU mortality.

Methodology/principal findings: A 2-year prospective, observational study of all first non-planned intubations, September 2007-9 in PICU and Intensive Care Transport team of Hôpital Robert Debré, Paris, 4 other PICUs and 5 NICUs in the Paris Region, France. Follow-up was from intubation to ICU discharge. A propensity score was used to adjust for patient specific characteristics influencing atropine prescription. 264/333 (79%) intubations were included. The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19-0.95, p=0.04). One child died during intubation (1/264, 0.4%). Two age sub-groups of neonates (≤28 days) and older children (>28 days, <8 years) were examined. This difference in mortality arose from the higher mortality in children aged over one month when atropine was not used (propensity score adjusted OR 0.22, 95%CI 0.06-0.85, p=0.028). No effect was seen in neonates (propensity score adjusted OR 1.3, 95%CI 0.31-5.1 p=0.74). Using the propensity score, atropine maintained the mean heart rate 45.9 bpm above that observed when no atropine was used in neonates (95%CI 34.3-57.5, p<0.001) and 43.5 bpm for older children (95%CI 25.5-61.5 bpm, p<0.001).

Conclusions/significance: Atropine use during induction was associated with a reduction in ICU mortality in children over one month. This effect is independent of atropine's capacity to attenuate bradycardia during intubation which occurred similarly in neonates and older children. This result needs to be confirmed in a study using randomised methodology.

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Related in: MedlinePlus

Kaplan-Meier plots for mortality in the two age sub-groups of neonates and older children.
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pone-0057478-g002: Kaplan-Meier plots for mortality in the two age sub-groups of neonates and older children.

Mentions: The unadjusted mortality prior to PICU discharge was 7% (9/124 [95%CI 4–13]) for those who received atropine compared to 16% (22/140 [95%CI 11–23]) for those who did not (OR 0.42, 95%CI 0.19–0.95 p = 0.04). The median mortality estimated by using the PRISM score was 8% [3]–[30] without atropine and 5% [2]–[12] with atropine. The standardised mortality ratio (SMR) between using the PRISM score as predictor of mortality (for the 94/111children for whom the score was available) was 1.05 for the whole group and 1.16 for the no-atropine versus 0.74 for the atropine groups. Ethomidate was used for 10 intubations, five with and five without atropine. All the children who received atropine survived with three deaths amongst those who did not receive atropine. Atropine use was associated with a significant difference in the survival of the older children (p = 0.005) but not neonates (p = 0.57) (Figure 2). The excess mortality present in older children with non-neonatal respiratory, cardiac and septic shock categories (Table 2).


Atropine for critical care intubation in a cohort of 264 children and reduced mortality unrelated to effects on bradycardia.

Jones P, Peters MJ, Pinto da Costa N, Kurth T, Alberti C, Kessous K, Lode N, Dauger S - PLoS ONE (2013)

Kaplan-Meier plots for mortality in the two age sub-groups of neonates and older children.
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC3585379&req=5

pone-0057478-g002: Kaplan-Meier plots for mortality in the two age sub-groups of neonates and older children.
Mentions: The unadjusted mortality prior to PICU discharge was 7% (9/124 [95%CI 4–13]) for those who received atropine compared to 16% (22/140 [95%CI 11–23]) for those who did not (OR 0.42, 95%CI 0.19–0.95 p = 0.04). The median mortality estimated by using the PRISM score was 8% [3]–[30] without atropine and 5% [2]–[12] with atropine. The standardised mortality ratio (SMR) between using the PRISM score as predictor of mortality (for the 94/111children for whom the score was available) was 1.05 for the whole group and 1.16 for the no-atropine versus 0.74 for the atropine groups. Ethomidate was used for 10 intubations, five with and five without atropine. All the children who received atropine survived with three deaths amongst those who did not receive atropine. Atropine use was associated with a significant difference in the survival of the older children (p = 0.005) but not neonates (p = 0.57) (Figure 2). The excess mortality present in older children with non-neonatal respiratory, cardiac and septic shock categories (Table 2).

Bottom Line: The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19-0.95, p=0.04).Atropine use during induction was associated with a reduction in ICU mortality in children over one month.This result needs to be confirmed in a study using randomised methodology.

View Article: PubMed Central - PubMed

Affiliation: Critical Care Group - Portex Unit, Institute of Child Health, University College London, London, Great Britain.

ABSTRACT

Background: Atropine has is currently recommended to facilitate haemodynamic stability during critical care intubation. Our objective was to determine whether atropine use at induction influences ICU mortality.

Methodology/principal findings: A 2-year prospective, observational study of all first non-planned intubations, September 2007-9 in PICU and Intensive Care Transport team of Hôpital Robert Debré, Paris, 4 other PICUs and 5 NICUs in the Paris Region, France. Follow-up was from intubation to ICU discharge. A propensity score was used to adjust for patient specific characteristics influencing atropine prescription. 264/333 (79%) intubations were included. The unadjusted ICU mortality was 7.2% (9/124) for those who received atropine compared to 15.7% (22/140) for those who did not (OR 0.42, 95%CI 0.19-0.95, p=0.04). One child died during intubation (1/264, 0.4%). Two age sub-groups of neonates (≤28 days) and older children (>28 days, <8 years) were examined. This difference in mortality arose from the higher mortality in children aged over one month when atropine was not used (propensity score adjusted OR 0.22, 95%CI 0.06-0.85, p=0.028). No effect was seen in neonates (propensity score adjusted OR 1.3, 95%CI 0.31-5.1 p=0.74). Using the propensity score, atropine maintained the mean heart rate 45.9 bpm above that observed when no atropine was used in neonates (95%CI 34.3-57.5, p<0.001) and 43.5 bpm for older children (95%CI 25.5-61.5 bpm, p<0.001).

Conclusions/significance: Atropine use during induction was associated with a reduction in ICU mortality in children over one month. This effect is independent of atropine's capacity to attenuate bradycardia during intubation which occurred similarly in neonates and older children. This result needs to be confirmed in a study using randomised methodology.

Show MeSH
Related in: MedlinePlus