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Emergent endotracheal intubations in children: be careful if it's late when you intubate

Christopher L Carroll¹, Philip C Spinella, John M Corsi

¹Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT, USA. ccarrol@ccmckids.org

Pediatric Critical Care Medicine : a Journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

|May 14, 2010

Insights

Emergent endotracheal intubations in children are common and more likely to occur off-hours. These procedures carry a significantly higher risk of complications compared to non-emergent intubations.

Area of Science:

Pediatric Critical Care Medicine
Emergency Medicine
Respiratory Care

Background:

Emergent endotracheal intubation in adults is linked to increased morbidity and mortality.
Children may face heightened risks due to age-specific anatomical and physiological differences.
The risks associated with emergent endotracheal intubations in pediatric populations have not been extensively studied.

Purpose of the Study:

To investigate and define the specific risks of emergent endotracheal intubations in children.
To compare complication rates between emergent and non-emergent pediatric intubations.
To identify factors contributing to complications during pediatric endotracheal intubation.

Main Methods:

Retrospective cohort study design.
Data collected from a 122-bed children's hospital between October 2005 and October 2007.
Included all non-elective endotracheal intubations performed outside the operating room, classifying them as emergent based on clinical data.

Main Results:

56% of 137 intubations were emergent, with a higher likelihood of occurring off-hours (OR 2.0).
Emergent intubations were associated with a threefold increased risk of complications (OR 3.0).
Common complications included desaturations (29%), hypotension (16%), and bradycardia (7%).

Conclusions:

Emergent endotracheal intubations in children are frequent and predominantly occur during off-hours.
Pediatric emergent intubations present a substantially elevated risk of complications.
Factors such as emergent status, off-hours timing, multiple attempts, and smaller tube size correlate with increased complication rates.

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Abstract

Objective:

Emergent endotracheal intubations carry a high risk of morbidity and mortality in critically ill adults. Although children may be at higher risk during this procedure as a result of age-related differences in anatomy and physiology, this has not been previously examined. The purpose of this study was to delineate the risks of emergent endotracheal intubations in children.

Design:

Retrospective cohort study.

Setting:

A 122-bed free-standing children's hospital.

Patients:

We conducted a retrospective review of all intubations occurring outside of the operating room setting between October 2005 and October 2007. Elective intubations were excluded. Intubations were classified as emergent after review of the child's vital signs, blood gas values, and written documentation by nurses, respiratory therapists, and physicians. Intubations occurring on weekends or between 5 pm and 8 am on weekdays were categorized as "off-hours."

Interventions:

None.

Measurements And Main Results:

During the study period, 137 intubations were performed, 77 of which (56%) were emergent. Emergent endotracheal intubations were significantly more likely to occur off-hours (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) and to be associated with a complication (odds ratio, 3.0; 95% confidence interval, 1.4-6.1). Complications occurred in 41% of all intubations. The most common complications were desaturations (29% of all intubations), hypotension (16%), and bradycardia (7%). In a multivariate logistic regression analysis, emergent intubation, off-hours intubation, three or more attempts at intubation, smaller endotracheal tube size, and admission for cardiovascular disease all increased the likelihood of experiencing a complication during intubation. Complications were not associated with an indication for intubation or baseline chronic disease of the child and were not associated with prolonged intensive care unit course or duration of mechanical ventilation.

Conclusions:

Emergent endotracheal intubations are commonly performed in children, are two times more likely to occur off-hours, and are associated with three times the risk of complications as nonemergent intubations.

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