292 First-Pass Success and Adverse Events in the Emergency Intubation of Children

While first-pass intubation success rates are similar for adults and children, pediatric intubation is an infrequent and stressful event in most emergency departments (ED). A report from the 2002-2012 National Emergency Airway Registry (NEAR) showed infants are at highest risk for first-pass intubation failure. Our goal was to describe patient factors and intubation practices in the emergency intubation of young children and estimate their associations with first-pass success and adverse events (AE). We performed a secondary analysis of prospectively collected data from the National Emergency Airway Registry (NEAR), a multicenter registry of academic and community EDs in the United States requiring reporting of ≥90% of intubations for participation. Patients ≤15 years of age were included from 2016 through 2018. We report proportions with associated 95% CIs and multivariable logistic regression estimating the association between age and first pass success and AE (bradycardia, hypotension, cardiac arrest, and hypoxia) accounting for clustering within hospitals and adjusting for indication for intubation, intubator level of training, sedative and paralytic choice, pretreatment, type of laryngoscope, and pre-intubation blood pressure and oxygen saturation. 25 EDs provided data for 612 pediatric intubations with a median age of 4 years (IQR 1-10) and 47% <3 years of age. Overall intubation success was 100%; first-pass success was 78.4% for all ages and lowest in children <1 year (66%); AE occurred in 15.5% of intubation attempts. After adjusting for confounding, younger age had significantly decreased odds of first-pass success (<1 year OR 0.34, 95% CI 0.18-0.62, 1-3 years OR 0.55, 95% CI 0.32-0.96) and significant increased odds of AE (<1 year OR 7.43, 95% CI 3.37-16.40, 1-3 years OR 3.80, 95% CI 1.97-7.35) compared with children >3 years. Pre-intubation cardiac arrest was the only covariate significantly associated with decreased first pass success (OR 0.31, 95%Cl 0.11-0.90). In this multicenter prospective cohort of pediatric emergency intubations, we found children <3 years of age were more commonly intubated than older children and experienced decreased odds of first pass success and increased odds of adverse events.