Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects Found by Video Review

Study objective

Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED).

Methods

We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success.

Results

We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined.

Conclusion

Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.

Introduction

Rapid sequence intubation (RSI) is the standard for definitive airway management in emergency medicine.1, 2, 3, 4 The administration, in rapid succession, of sedative and neuromuscular-blocking medications is designed to optimize conditions for emergency intubation while limiting the risk of patient harm. RSI is reported to be a highly successful and safe procedure among adult emergency department (ED) patients,1, 2, 4 with one multicenter study reporting success on the first attempt for 85% of these patients.² Children are thought to be at greater risk during emergency intubation, for both failed attempts and adverse effects.¹ To our knowledge, there are few studies that report pediatric-specific data for RSI in an ED, all of which have important limitations.3, 5, 6, 7, 8, 9

In a report from the National Emergency Airway Registry, 156 children (18 years or younger) had tracheal intubation attempted in an ED setting, including 1 pediatric ED. For the 127 children who underwent RSI, 78% were tracheally intubated on the first attempt and 16% had at least 1 adverse effect (including 2% with desaturation, 7% with mainstem intubation, and 4% with esophageal intubation).³ In a separate retrospective study of 143 children tracheally intubated in a pediatric ED, bradycardia was reported in 4% of patients and hypoxemia in 22%.⁵ These studies likely underreport the frequency of both first-attempt failure and adverse effects because of voluntary self-reporting or the limitations of chart review. Our clinical experience and quality assurance efforts suggested that failed first attempts and adverse effects occur more commonly than reported for pediatric emergency patients undergoing RSI.

RSI is among the most common critical procedures performed for pediatric emergency patients and should be a high priority for quality assurance efforts.9, 10, 11 First-attempt success is used as a measure of the quality of the RSI process and the ease of tracheal intubation.2, 3 The failure of early attempts at tracheal intubation may deplete a patient's oxygen reserve, leading to physiologic deterioration of an already critically ill or injured child. An accurate description of the frequency of first-attempt success and adverse effects of RSI for children in an ED setting will allow a better risk assessment and inform targeted interventions to reduce that risk.

The goal of our study was to accurately and thoroughly describe the process, success, and safety of RSI for patients in a busy pediatric ED. Using video review, we specifically sought to determine the frequencies of first-attempt success and adverse effects for patients undergoing RSI in a pediatric ED.