Intubating critically ill children: each extra attempt raised the odds of cardiac arrest by 70%

Design

Retrospective analysis of a prospective multicentre intubation registry

Population

27,773 intubations in 68 paediatric and paediatric cardiac ICUs, 2015 to 2023

Primary outcome

Intubation-associated cardiac arrest within 20 minutes

Effect

1.2% overall; per extra attempt aOR 1.70 (1.56 to 1.85); shock aOR 4.67

This analysis used a prospective international registry covering 27,773 first intubations in 68 paediatric and paediatric cardiac ICUs from 2015 to 2023. Intubation-associated cardiac arrest was defined as arrest or at least a minute of chest compressions within 20 minutes of tube placement.

Arrest occurred in 1.2%. Shock before intubation was associated with much higher odds (adjusted odds ratio 4.67), as was failed oxygenation (2.29). Each additional attempt raised the odds by about 70% (1.70 per attempt). Video laryngoscopy (0.76), ketamine (0.64), propofol (0.44) and neuromuscular blockade (0.67) were associated with lower odds. Only 13% of the video laryngoscopy association ran through fewer attempts.

The lessons apply in the emergency department as much as the ICU: resuscitate before intubating, plan for first-pass success, and use the device and drugs that support it. The propofol finding likely reflects which children received it — the more stable ones — so it is not a reason to choose propofol in shock.

• Correct hypotension and pre-oxygenate before intubating a critically ill child.
• Plan for first-pass success with the most experienced operator available.
• Consider video laryngoscopy where available.
• Consider ketamine for induction in children with haemodynamic instability.
• Consider neuromuscular blockade to improve intubating conditions.

Why it matters

Peri-intubation arrest is one of the few ICU catastrophes that is partly predictable and preventable.

Don't overread it

Registry associations; the drug findings especially reflect which children received which drugs.

The statistics, in plain English

An adjusted odds ratio of 1.70 per attempt compounds: three attempts carry roughly three times the odds of a first-pass intubation. These are associations from a registry, and sicker children are both harder to intubate and more likely to arrest, so not every difference is caused by the technique.

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