- Design
- Retrospective analysis of a prospective multicentre registry
- Population
- 27,773 first intubations in critically ill children in 68 paediatric ICUs
- Primary outcome
- Cardiac arrest within 20 minutes of intubation
- Effect
- 1.2% overall; aOR 1.70 (1.56–1.85) per additional attempt; shock aOR 4.67
The National Emergency Airway Registry for Children collected data prospectively on 27,773 first intubations in 68 international paediatric and paediatric cardiac ICUs between 2015 and 2023. Cardiac arrest within 20 minutes of tube placement occurred in 1.2% (331 children).
Shock before intubation (aOR 4.67, 95% CI 3.68–5.92) and oxygenation failure (aOR 2.29) were associated with higher odds of arrest. Each additional attempt raised the odds further (aOR 1.70 per attempt). Ketamine (aOR 0.64), propofol (aOR 0.44), neuromuscular blockade (aOR 0.67) and video laryngoscopy (aOR 0.76) were associated with lower odds. Only about 13% of video laryngoscopy's association was explained by fewer attempts.
This is registry data, so the drug and device associations may reflect who chose them and when. Propofol in particular may have been used in more stable children. But the gradient with attempts is consistent and matches adult data, and the risk factors — shock and hypoxia — are ones a team can partly correct before starting.
The lessons apply to any emergency department or ICU intubating a sick child: optimise first, aim for first-pass success, and have the most experienced operator and best device ready from the outset.
- Optimise oxygenation and haemodynamics before intubating a critically ill child where time allows.
- Aim for first-pass success: the most experienced operator and video laryngoscope ready from the first attempt.
- Consider neuromuscular blockade to improve intubating conditions, unless contraindicated.
- Set a limit on attempts before moving to a rescue plan.
- Have resuscitation drugs drawn up before induction in a child in shock.
Why it matters
The second and third attempts are where routine airway care becomes resuscitation.
Don't overread it
Associations with ketamine, propofol and video laryngoscopy come from registry data and do not show those choices cause fewer arrests.
The statistics, in plain English
An adjusted odds ratio of 1.70 per attempt means each extra attempt raised the odds of arrest by about 70%, compounding. Associations with drugs and devices come from observational data, where choice of technique is linked to how sick the child was.
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