The importance of first pass success when performing orotracheal intubation in the emergency department.

OBJECTIVES The goal of this study was to determine the association of first pass success with the incidence of adverse events (AEs) during emergency department (ED) intubations. METHODS This was a retrospective analysis of prospectively collected continuous quality improvement data based on orotracheal intubations performed in an academic ED over a 4-year period. Following each intubation, the operator completed a data form regarding multiple aspects of the intubation, including patient and operator characteristics, method of intubation, device used, the number of attempts required, and AEs. Numerous AEs were tracked and included events such as witnessed aspiration, oxygen desaturation, esophageal intubation, hypotension, dysrhythmia, and cardiac arrest. Multivariable logistic regression was used to assess the relationship between the primary predictor variable of interest, first pass success, and the outcome variable, the presence of one or more AEs, after controlling for various other potential risk factors and confounders. RESULTS Over the 4-year study period, there were 1,828 orotracheal intubations. If the intubation was successful on the first attempt, the incidence of one or more AEs was 14.2% (95% confidence interval [CI] = 12.4% to 16.2%). In cases requiring two attempts, the incidence of one or more AEs was 47.2% (95% CI = 41.8% to 52.7%); in cases requiring three attempts, the incidence of one or more AEs was 63.6% (95% CI = 53.7% to 72.6%); and in cases requiring four or more attempts, the incidence of one or more AEs was 70.6% (95% CI = 56.2.3% to 82.5%). Multivariable logistic regression showed that more than one attempt at tracheal intubation was a significant predictor of one or more AEs (adjusted odds ratio [aOR] = 7.52, 95% CI = 5.86 to 9.63). CONCLUSIONS When performing orotracheal intubation in the ED, first pass success is associated with a relatively small incidence of AEs. As the number of attempts increases, the incidence of AEs increases substantially.

[1]  Hiroko Watase,et al.  Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. , 2012, Annals of emergency medicine.

[2]  Daniel J Pallin,et al.  Emergency airway management: a multi-center report of 8937 emergency department intubations. , 2011, The Journal of emergency medicine.

[3]  T. Mort.  The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA Guidelines in the remote location. , 2004, Journal of clinical anesthesia.

[4]  J. Marx,et al.  Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. , 1999, Academic emergency medicine : official journal of the Society for Academic Emergency Medicine.

[5]  M. Matthay,et al.  Death and Other Complications of Emergency Airway Management in Critically Ill Adults: A Prospective Investigation of 297 Tracheal Intubations , 1995, Anesthesiology.

[6]  D. Hess,et al.  Effects of Supervision by Attending Anesthesiologists on Complications of Emergency Tracheal Intubation , 2008, Anesthesiology.

[7]  A. Bair,et al.  Feasibility of the preoperative Mallampati airway assessment in emergency department patients. , 2010, The Journal of emergency medicine.

[8]  J. Barker.  3,423 Emergency Tracheal Intubations at a University Hospital: Airway Outcomes and Complications , 2011 .

[9]  R. Levitan,et al.  Limitations of difficult airway prediction in patients intubated in the emergency department. , 2004, Annals of emergency medicine.

[10]  D. Doyle.  Practice Guidelines for Management of the Difficult Airway: An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway , 2003, Anesthesiology.

[11]  R. Walls,et al.  Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. , 2005, Annals of emergency medicine.

[12]  T. Mort,et al.  Emergency Tracheal Intubation: Complications Associated with Repeated Laryngoscopic Attempts , 2004, Anesthesia and analgesia.