DOI: 10.1097/ccm.0000000000007390 ISSN: 0090-3493

Comparative Analysis of Tracheal Intubation–Associated Cardiac Arrest in 2015–2023: A Report From the National Emergency Airway Registry for Children Multicenter Registry

Asif Padiyath, Febina Padiyath, Robert A. Berg, Natalie Napolitano, Vinay Nadkarni, Justine Shults, Knashawn H. Morales, Annery Garcia-Marcinkiewicz, Christopher Page-Goertz, Jordan W. Newman, Ilana Harwayne-Gidansky, Laurence Ducharme-Crevier, Ronald C. Sanders, Ashley D. Freeman, Fabrizio Chiusolo, Ryan Breuer, Amy Romer, Lily B. Glater Welt, Jennifer Shenker, Kelly L. Corbett, Palen P. Mallory, Mark V. Mai, Lee A. Polikoff, Ashwin S. Krishna, Asha Shenoi, Mervin V. Loi, Matthew Pinto, Gokul Kris Bysani, Anthony Lee, Masafumi Gima, Andrea Talukdar, Kimberly McMahon, Maria Libertin, Serena P. Kelly, Conrad Krawiec, Aline Branca, David W. Tellez, Robert A. Levy, Gabrielle A. Nuthall, Curtis Kovaleski, Mark Piehl, Awni M. Al-Subu, Aziez Ahmed, John S. Giuliano, Akira Nishisaki,
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Objectives:

To determine the contemporary incidence of tracheal intubation–associated cardiac arrest (TI-CA) in critically ill children and identify potentially modifiable factors to prevent TI-CA in PICUs and pediatric cardiac ICUs (PCICUs).

Design:

Retrospective cohort study

Setting:

Seventy international PICUs and PCICUs

Patients:

Critically ill children requiring tracheal intubation in PICUs and PCICUs

Interventions:

Tracheal intubation data were prospectively collected for all initial intubations in 68 PICUs and PCICUs from January 2015 to December 2023 using the National Emergency Airway Registry for Children registry.

Measurements and Main Results:

TI-CA was defined as CA occurrence or receipt of chest compressions for at least 1 minute within 20 minutes of endotracheal tube placement. TI during ongoing cardiopulmonary resuscitation was not considered TI-CA. A total of 27,773 TIs were evaluated, with TI-CA reported in 1.2% ( n = 331). Pre-TI oxygenation failure and shock were associated with higher odds of TI-CA (adjusted odds ratio [aOR], 2.29; 95% CI, 1.81–2.89 and aOR, 4.67; 95% CI, 3.68–5.92, respectively). Each additional TI attempt required was associated with increased odds of TI-CA (aOR, 1.70; 95% CI, 1.56–1.85, for each attempt). Use of ketamine (aOR, 0.64; 95% CI, 0.49–0.82), propofol (aOR, 0.44; 95% CI, 0.27–0.72), neuromuscular blockade (aOR, 0.67; 95% CI, 0.49–0.91), and video laryngoscopy (aOR, 0.76; 95% CI, 0.6–0.97) were associated with lower odds of TI-CA. Mediation analysis indicated that 13% of video laryngoscopy’s protective effect was due to a reduction in TI attempt counts. The protective effects of ketamine, propofol, and neuromuscular blockade were minimally mediated by reduced TI attempt counts (5%, 4%, and 7%).

Conclusions:

TI-CA occurred in 1.2% of TIs performed in the PICUs. Odds of TI-CA increased incrementally with successive TI attempts. Video laryngoscopy was protective against TI-CA. Mediation analysis revealed that reduced TI attempts accounted for 13% of the protective benefit associated with video laryngoscopy.

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