Elsevier

Annals of Emergency Medicine

Volume 60, Issue 6, December 2012, Pages 749-754.e2
Annals of Emergency Medicine

Airway/original research
Association Between Repeated Intubation Attempts and Adverse Events in Emergency Departments: An Analysis of a Multicenter Prospective Observational Study

https://doi.org/10.1016/j.annemergmed.2012.04.005Get rights and content

Study objective

Although repeated intubation attempts are believed to contribute to patient morbidity, only limited data characterize the association between the number of emergency department (ED) laryngoscopic attempts and adverse events. We seek to determine whether multiple ED intubation attempts are associated with an increased risk of adverse events.

Methods

We conducted an analysis of a multicenter prospective registry of 11 Japanese EDs between April 2010 and September 2011. All patients undergoing emergency intubation with direct laryngoscopy as the initial device were included. The primary exposure was multiple intubation attempts, defined as intubation efforts requiring greater than or equal to 3 laryngoscopies. The primary outcome measure was the occurrence of intubation-related adverse events in the ED, including cardiac arrest, dysrhythmia, hypotension, hypoxemia, unrecognized esophageal intubation, regurgitation, airway trauma, dental or lip trauma, and mainstem bronchus intubation.

Results

Of 2,616 patients, 280 (11%) required greater than or equal to 3 intubation attempts. Compared with patients requiring 2 or fewer intubation attempts, patients undergoing multiple attempts exhibited a higher adverse event rate (35% versus 9%). After adjusting for age, sex, principal indication, method, medication, and operator characteristics, intubations requiring multiple attempts were associated with an increased odds of adverse events (odds ratio 4.5; 95% confidence interval 3.4 to 6.1).

Conclusion

In this large Japanese multicenter study of ED patients undergoing intubation, we found that multiple intubation attempts were independently associated with increased adverse events.

Introduction

Intubation is a critical intervention performed in the emergency department (ED). Previous studies have described adverse events associated with intubation in this clinical setting, such as airway trauma, esophageal intubation, aspiration, hypoxemia, hypotension, dysrhythmia, and cardiac arrest.1, 2, 3, 4, 5, 6, 7, 8, 9, 10 Despite emphasis on “first-pass intubation success,” other studies suggest that 3% to 12% of all ED intubations require multiple laryngoscopic efforts.2, 4, 5, 7, 8, 11

International anesthesia consensus standards recommend limiting airway management efforts to a total of 3 laryngoscopy attempts, with subsequent rescue use of supraglottic or alternate airway devices.12, 13 However, there has been little clinical evidence to support this strategy in the ED, where airway management is typically performed by emergency physicians on acutely ill patients. The relationship between multiple ED intubation attempts and adverse patient outcomes has not been studied, to our knowledge.

We aimed to determine whether multiple intubation attempts are associated with airway-associated adverse events in patients undergoing intubation in the ED.

Section snippets

Study Design and Setting

This study was a secondary analysis of the Japanese Emergency Airway Network Registry, a prospective observational multicenter data registry designed to characterize the current ED airway management across Japan. The study setting, methods of measurement, and measured variables have been reported previously.14 In summary, the registry is a consortium of 11 academic and community medical centers from different geographic regions across Japan. All 11 EDs were staffed by emergency attending

Results

During the 18-month period, there were 2,788 subjects requiring emergency airway management (Figure). Among these, the database recorded 2,710 intubations (capture rate 98%). We excluded 94 patients undergoing initial airway management by nasal intubation, cricothyrotomy, or accessory devices. We included the remaining 2,616 patients studying the analysis.

The mean age of patients receiving intubation was 64 years (Table 1). Most intubations involved medical emergencies. One third of patients

Limitations

Surveillance systems such as that used in this study are subject to self-reporting bias, leading to an underestimation of adverse event rates.18 However, real-time independent monitoring of ED airway management is difficult to accomplish. We used a previously applied self-reporting system with structured data forms, uniform definitions, and a high capture rate.4 We believe that these data represent the best available data. Despite these limitations, we detected a high rate of adverse events. We

Discussion

Despite its ubiquitous presence in contemporary emergency medicine practice, many vital questions about ED airway management remain unanswered.19 Ironically, the majority of scientific evidence of emergency airway management originates from out-of-hospital and anesthesia settings; we lack similar insights about airway management in the ED.20, 21, 22, 23, 24, 25, 26 In the out-of-hospital and anesthesia literature, tracheal injury, hypoxemia, and other intubation-related adverse events have been

References (33)

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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. This study was supported by a grant from St. Luke's Life Science Institute and a grant from Massachusetts General Hospital and Brigham and Women's Hospital. The study sponsors had no involvement in the study design; in the collection, analysis, and interpretation of data; in the writing of the article; or in the decision to submit the article for publication.

Please see page 750 for the Editor's Capsule Summary of this article.

Supervising editor: Henry E. Wang, MD, MS

Author contributions: KH, KS, and DFMB conceived the study. KH obtained research funding. KH, YH, TC, HW, and CAB supervised the conduct of the trial and data collection. YH, TC, and HW managed the data, including quality control. YH and HW provided statistical advice on study design and analyzed the data. KH chaired the data oversight committee. KH drafted the article, and all authors contributed substantially to its revision. KH takes responsibility for the paper as a whole.

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Publication date: Available online April 28, 2012.

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