- Email: [email protected]
Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study
YAJEM-58306; No of Pages 6 American Journal of Emergency Medicine xxx (xxxx) xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study Syunsuke Yamanaka, MD a,b,⁎, Ran D. Goldman, MD, FRCPC a, Tadahiro Goto, MD, MPH c, Hiroyuki Hayashi, MD b a b c
Department of Pediatrics, University of British Columbia, Vancouver, Canada Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan Graduate School of Medical Sciences, University of Fukui, Japan
a r t i c l e
i n f o
Article history: Received 26 February 2019 Received in revised form 16 June 2019 Accepted 18 June 2019 Available online xxxx
a b s t r a c t Objectives: Multiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization. Methods: We conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED. Results: Of 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p b 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24–2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93–0.98, p b 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04–0.56, p b 0.01) were independent prognostic variables. Conclusions: We found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Tracheal intubation is a frequent lifesaving procedure for critically ill patients in the Emergency Department (ED). Rapid and effective intubation is important but success rate of first intubation attempt in the ED setting varies significantly, ranging from 70.8 to 94.0% in a comparison of previous studies [1]. Approximately 12%–15% of patients that underwent intubation suffer from intubation-related adverse events [2-4], and multiple intubation attempts are associated with increased rate of adverse events such as vomiting, hypotension, airway injury and cardiac arrest during and immediately after intubation [5]. The number of intubation attempts has been considered by some as an index for intubation quality [6], but others argue that due to high rate of adverse events during the first intubation attempt, including cardiac
arrest [7] and abnormal physiologic reactions [8], first-pass success should not be regarded as a quality indicator. Therefore, transient adverse events associated with first pass success may not be clinically meaningful for long term outcomes. Furthermore, to our knowledge, no studies have examined the association between multiple intubation attempts in the ED, and morbidity and mortality during hospitalization. To address the existing knowledge gap, we aimed to determine whether multiple intubation attempts (two or more) in the ED are associated with an increased morbidity and mortality in patients treated in a large medical center in Japan.
2. Methods 2.1. Study design and setting
⁎ Corresponding author at: Department of Pediatrics, University of British Columbia, Vancouver, Canada. E-mail addresses: [email protected] (S. Yamanaka), [email protected] (H. Hayashi).
This study was a retrospective analysis of medical records in a general medical center in Japan. The study received the University of Fukui Hospital Institutional Review Board approval with an exemption
https://doi.org/10.1016/j.ajem.2019.06.028 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
2
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
of an informed consent. This study received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The University of Fukui Hospital is an academic medical center certified as Level II equivalent trauma center with a census of 20,000 patient visits per year. The ED is staffed by a group of 18 emergency physicians. It is affiliated with an emergency medicine residency training program as well as a cohort of non-emergency residents. Intubations are performed by an attending physician or by a resident with direct supervision by an attending physician, a staff pediatrician, a staff neurosurgeon or a staff general surgeon. 2.2. Participants All consecutive patients who underwent emergency intubation during a 69-month period (September 1st 2010 to Apr 30th 2016), were included in the study. This period was selected based on availability of the primary author. We excluded patients who died prior to successful intubation in the ED. Patients who presented to the ED in cardiac arrest without revival were also excluded, as did patients who died shortly after intubation in the ED, and patients who were transferred to another facility from our ED following intubation. Cardiac arrest survivors with return of spontaneous circulation (ROSC) were included. 2.3. Data collection Data collection was done by the primary physician providing care for the patient, or by a physician that worked with the primary physician after each intubation in the ED, using a standardized data collection form that was designed by the Japanese Emergency Airway Network. The study methods of measurement have been previously described [2]. When data was missing, we performed post hoc interviews with the physician involved within two weeks of the encounter. We also monitored compliance with data form completion by reviewing professional billing records. Additional data related to hospitalization was obtained by the primary investigator reviewing charts in the hospital medical records department. 2.4. Measurements We collected the following variables: demographic information (patient age, sex, body mass index [BMI]), intubation related data (number of intubation attempts, time of day, day of the week, intubation method, intubation device, intubator's specialty [junior resident or senior physicians], indication for intubation, relevant medical condition, length of time the patient was intubated) and ED and hospital course (length of stay [LOS] in the hospital, in the intensive care unit [ICU], in the ED, and final disposition). Intubation method refers to medication/technique (i.e. rapid sequence intubation [RSI], sedatives without paralytics, or intubation without medications in the setting of cardiac arrest.). We considered intubation to be conducted by ‘Junior physicians’ when these were ‘junior residents’ in the first 2 years of residency (in Japan these residents rotate in different specialties and considered ‘junior’) after completing medical school (post graduate year [PGY] 1 and 2) [2]. ‘Senior physicians’ were residents committed to the specialty of EM (PGY 3,4,5), ED attending physicians, anesthesiologists and pediatricians. Indication for intubation included the following four categories [9,10]: (1) respiratory problems including internal airway obstruction, airway burn and respiratory failure such as asthma, (2) Cardiac arrest including internal or traumatic causes, (3) altered mental status due to septic shock, subarachnoid hemorrhage, neurologic disease and other internal-medicine reasons such as toxic/metabolic/infectious encephalopathy and status epilepticus, and (4) altered mental status due to traumatic causes such as multiple system injuries, traumatic shock, head injuries and face/neck injuries. Medical conditions were considered: brain-related, cardiovascular-related, multiple injuries and other
conditions (simple face/neck injury, neurologic diseases, poisoning, pulmonary diseases, sepsis and urinary tract infections). 2.5. Outcomes The primary outcome measure was mortality during hospitalization after intubation in the ED. The secondary outcome measures were disposition, hospitalization LOS, ICU LOS, and days to extubation. Mortality during hospitalization, LOS in hospital, LOS in ICU and days to extubation were determined by medical records that stored in the computerized medical records system. Days to extubation was defined as the number of days between day of intubation and the day of extubation. The primary exposure was the occurrence of multiple intubation attempts, defined as two or more intubation attempts. An intubation “attempt” was defined as a single insertion of the laryngoscope past the teeth [11]. An attempt was successful if it resulted in a tracheal tube being placed through the vocal cords, with confirmation by quantitative or colorimetric end-tidal carbon dioxide monitoring. 2.6. Statistical analysis Continuous variables were presented as mean, median and interquartile range (IQR) for LOS and intubation period. Categorical variables were presented as frequencies and percentages. Patients were dichotomized into successful intubation on first attempt, and those needing more than one attempt group. The difference in primary and secondary outcomes between groups were reported. Independent t-test or MannWhitney U test was performed for continuous variables. Chi-square and Fisher's exact test were used to examine the difference between categorical variables. We also fit multivariable logistic regression models to examine the association of number of intubation attempts in the ED and morbidity and mortality outcomes. We selected variables as a set of potential confounders based on biological plausibility and previous knowledge. These included age, sex, intubation methods, level of physician performing the first intubation and diagnostic category [2,3,12-14]. Data were analyzed using SPSS (SPSS version 25; IBM corporation, Armonk, New York, USA). All probability was two-tailed, and p value of b0.05 was considered statistically significant. The primary authors had full access to the data and were responsible for its integrity. 3. Results A total of 266 patients were intubated in the ED during the study period. Of these 81 (30.5%) were excluded as they were declared dead in the ED, 4 (1.5%) were excluded because they were transferred to another hospital after intubation and no follow-up data was available. Of the remaining 181 patients, 118 (65.2%) were intubated successfully on the initial attempt and 63 (34.8%) patients needed multiple (2 or more) intubation-attempts. Comparison between the groups is presented in Table 1. One hundred and one patients (55.8%) were males; mean age was 64.2 years (median 68, interquartile range (IQR) 56–80). The majority of patients (149, 82.3%) were intubated by a senior physician (ED attending physician, ED senior resident, anesthesiologist or pediatrician). A direct laryngoscope was the most frequently used device for first intubation attempt (165, 91.2%). Medications, including those for RSI, were used in 115 (63.5%) patients. More than half of the patients (106, 58.6%) were intubation due to internal-medicine conditions and change in consciousness, followed by traumatic causes of unconsciousness (37, 20.4%), and those that survived cardiac arrest (18, 9.9%). As diagnostic category, thirteen patients were missed and we used 161 as denominator, more than half (90, 55.2%) of patients were intubated due to brain injury, followed by cardiovascular diseases (17, 10.4%) and other conditions (44, 27%). Esophageal intubation (8, 4.4%) was the most common adverse event, followed by hypotension (5, 2.8%) and main bronchus intubation
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
3
Table 1 Patient's characteristics and comparison of successful intubation after first attempt and on subsequent attempts. Trial Sex n (%) Male Female Median age (years) (IQR) Median BMI Time of day for intubation n (%) Day (8 am–5 pm) Night (5 pm–12 pm) Overnight (midnight–8 am) Day of the week n (%) Weekday Weekend (Saturday-Sunday) Intubation method n (%) Medicationa No medications used Intubation device n (%) Laryngoscope Video laryngoscopy Level of first intubator n (%) Junior resident (PGY1 to 2) Senior resident/staff physicianb Indication for intubation n (%) Respiratory compromisec Cardiac arrest Internal disturbance of consciousness Traumatic disturbance of consciousness and face injury Diagnostic category n (%) Brain Cardiovascular Multiple injury Otherd
Successful intubation on first attempt (n = 118)
More than one attempt for successful intubation (n = 63)
Total (n = 181)
60 (50.8) 58 (49.2) 67 (56–79) 22.2
41 (65.1) 22 (34.9) 69 (55–81) 23.1
101 (55.8) 80 (44.2) 68 (56–80) 22.4
43 (36.4) 52 (44.1) 23 (19.5)
26 (41.3) 26 (41.3) 11 (17.5)
69 (38.1) 78 (43.1) 34 (18.8)
82 (69.5) 36 (30.5)
41 (65.1) 22 (34.9)
123 (68) 58 (32)
82 (69.5) 36 (30.5)
33 (52.4) 30 (47.6)
115 (63.5) 66 (36.5)
108 (91.5) 10 (8.5)
57 (90.5) 6 (9.5)
165 (91.2) 16 (8.8)
26 (22) 92 (78)
6 (9.5) 57 (90.5)
32 (17.7) 149 (82.3)
12 (10.2) 15 (12.7) 70 (59.3) 21 (17.8)
8 (12.7) 3 (4.8) 36 (57.1) 16 (25.4)
20 (11) 18 (9.9) 106 (58.6) 37 (20.4)
62 (60.2) 13 (12.6) 6 (5.8) 22 (21.4)
28 (46.7) 4 (6.7) 6 (10) 22 (36.7)
90 (55.2) 17 (10.4) 12 (7.4) 44 (27)
p -Value 0.07
0.87 0.15 0.81
0.55
0.02
0.81
0.04
0.26
0.08
IQR = interquartile range, BMI = Body Mass Index, RSI = Rapid Sequence Intubation, PGY = Post Graduate Year, ED = Emergency Department. Legend: There are significant differences in intubation methods and 1st intubator. Medication was used more in patients intubated successfully on the first attempt and the senior physician intubated more for patients requiring multiple intubations. a Defined as rapid sequence intubation, sedatives without paralytics, or paralytics without sedatives b Defined as ED attending physicians, ED senior resident (PGY 3–5), Anesthesiology and Pediatrics Staff physicians c Defined as internal airway obstruction, airway burn and respiratory failure. d Defined as simple face/neck injury, heating, lightening, neurologic diseases, poisoning, pulmonary diseases, sepsis, suffocation and urinary diseases.
(5, 2.8%). There were significantly more adverse events in multiple intubation attempts group (8.5% vs 33.3%, p b 0.01). Eighteen (9.9%) patients recovered and were admitted to our hospital after they were transferred to our ED with Cardiopulmonary Arrest (CPA). We found no significant differences in patient characteristics such as age, sex, BMI, indication for intubation, diagnostic category, time of day (shift), day of the week, or device used for first intubation attempt between the first pass intubation group and multiple intubation attempts group. We found the use of medications (defined as any use of medication including rapid sequence intubation, sedatives without paralytics, or paralytics without sedatives during the first intubation process) was associated with a higher rate of success (p = 0.02). Junior residents (PGY1 and 2) were more successful in intubating patients after one
attempt, compared to more senior physicians (p = 0.04). Morbidity and mortality variables related to patients after admission are described in Table 2. One hundred thirteen (62.4%) were discharged from the hospital. Of those, 36 (31.9%) discharged home and 77 (68.1%) were transferred to another hospital for long-term rehabilitation. Mean LOS in hospital, and ICU LOS was 44.8 days, and 9.9 days respectively. Mean intubation period was 6.6 days. There was no significant difference in hospital death rate, discharge disposition, LOS in hospital, ICU LOS, and intubation period between those successfully intubated after the first attempt or if more attempts were needed. To determine the association of intubation attempts in the ED with the mortality during hospitalization, we conducted a multivariate analysis to determine predictors of death. The odds ratio (OR) of intubation attempts for hospital death
Table 2 Adverse events and ventilation style after intubation in ED. Adverse events
Successful intubation on first attempt (n = 118)
More than one attempt for Successful Intubation (n = 63)
Total (181)
Main bronchus intubation Hypotension Esophagus intubation Teeth, lips, nose injury Vomiting (with no aspiration) Vomiting (with aspiration) Airway bleeding Sub total Ventilation style Spontaneous Forced ventilation Both
3 (2.5) 4(3.4) 0 1(0.8) 1(0.8) 0 1(0.8) 10(8.5)
2(3.2) 1(1.6) 8(12.7) 2(3.2) 1(1.6) 5(7.9) 2(3.2) 21(33.3)
5(2.8) 5(2.8) 8(4.4) 3(1.7) 2(1.1) 5(2.8) 3(1.7) 31(17.1)
11(9.7) 86(76.1) 16(14.2)
8(15.4) 36(69.2) 8(15.4)
19(11.5) 122(73.9) 24(14.5)
p-Value
b0.01 0.53
ED = Emergency Department
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
4
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
was 0.62 (95%CI 0.3–1.3, p = 0.21). In this model, use of medications during intubation was the only independent prognostic variables for hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p b 0.01). Number of attempts to achieve successful intubation was not associated with discharge disposition in our model (OR 0.77 95%CI 0.24–2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93–0.98, p b 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04–0.56, p b 0.01) were independent prognostic variables (Tables 3 and 4).
Table 4 Multivariate associations of in hospital death and discharge disposition.
In hospital death
4. Discussion Intubation is a critical procedure in maintaining patent airways and is frequently performed in the ED. First pass intubation, the successful intubation after a single attempt, has been shown to be important in reducing complications of airway management among adults and children [3,5,15-17], since multiple attempts and failed endotracheal intubations are associated with oxygen desaturation, arrhythmias, cardiac arrest, brain damage, and mortality in the ED [18-20]. Our study is the first to examine factors that may be associated with outcome of patients that were admitted to the hospital after multiple intubation attempts in the ED, using data collected from a large medical center in Japan. In our cohort, 65% of patients were successfully intubated on first attempt and 35% needed more than one attempt. We found that the use of drugs was associated with successful first attempt intubation, and that junior residents were more successful in first pass intubation, compared to more senior physicians. There were significantly more adverse events in patients with multiple intubation attempts. Using a multivariate analysis, we found that more than one intubation attempt in the ED did not adversely affect death rate or hospital discharge home. In contrast, medication use for intubation was the only significant predictive factor (p b 0.01) for patient death during hospitalization. 4.1. First pass success Multiple attempts for intubation are associated with increased adverse events such as vomiting, hypotension, airway injury and even cardiac arrest, during and immediately after intubation [5]. Based on a cohort of 1486 patients in the Japanese Emergency Airway Network, success rate of first attempt was 40–83% in different hospitals [10]. The incidence of cardiac arrest or death as adverse effect after intubation in the EDs was extremely low (0.2%) [11]. Vomiting (0.8%), dental trauma (1%), main bronchus intubation (2%), esophageal intubation with delayed recognition (3.9%) and hypotension (1.5%) were more common [10]. However, with physiologic alterations during emergency intubation, first pass intubation may not serve as a reliable predictor of quality of intubation or the patient's outcome. In one pre-hospital observational study from the US, among 134 patients with a median age of 55 years, desaturation occurred in 43%, bradycardia in 13% and hypotension in 7%. The majority (60–70%) of adverse events took place in those patients with first pass intubations [8]. In a matched case-control study
Discharge disposition
OR
Number of intubation attempts Age Sex Diagnostic category Brain Cardiovascular Multiple injuries Use of medications during intubation Experience of first intubator Number of Intubation attempts Age Sex Diagnostic category Brain Cardiovascular Multiple injury Use of medications during intubation Experience of first intubator
0.62
0.3–1.3
0.21
1.02 0.68
1–1.04 0.33–1.4
0.07 0.3
1.3 0.63 0.94
0.58–2.9 0.18–2.15 0.2–4.39
0.52 0.46 0.94
0.21 0.5 0.77
0.1–0.45 0.21–1.17 0.24–2.46
b0.01⁎ 0.11 0.66
0.95 1.02
0.93–0.98 0.35–3.1
b0.01⁎ 0.96
0.15 0.04–0.56 4.61 0.94–22.58 0.52 0.08–3.54
b0.01⁎ 0.06 0.52
0.22 0.73
95%CI
p-Value R2
Prognostic variables
0.61–8.11 0.19–3.12
0.19
0.38
0.22 0.73
OR = Odds ratio, CI = Confidence interval, R2 = Nagelkerke R square. ⁎ p b 0.01.
from South Korea, among 2403 patients (median age 64) who underwent intubation, 41 patients (1.7%) had a peri-intubation cardiac arrest, 36/41 (88%) occurred in patients with a first-attempt success. The investigators suggested that systolic hypotension shortly before intubation was the only factor associated with cardiac arrest, rather than the number of intubation attempts. The authors questioned the effect of first pass as a quality indicator since there was no relationship between multiple intubation attempts and cardiac arrest as a short-term adverse event. In terms of long-term adverse events such as inhospital death, to our knowledge, there are no previous studies and our findings failed to demonstrate that first pass success is associated with reduced in-hospital mortality or successful discharge home. We believe that multiple intubation attempts increase adverse events immediately after intubation [3,5,7,15-17]. However, its clinical impact on long-term outcomes is hard to determine. 4.2. Medication use Medication use in our cohort included the use of RSI medications, sedatives and paralytics, and was associated with successful first pass intubation. The higher success rate of RSI in our study is consistent with recent reports [5,17]. Using RSI was associated with a high level of success among EM residents [5]. In a secondary analysis of data from a multicenter prospective observational registry in 13 Japanese EDs, with 2365 patients, intubation with RSI, was independently associated with a higher success rate on first attempt [17]. Our study further strengthened the basis of RSI use in the emergency room.
Table 3 Comparison of morbidity and mortality variables with successful intubation attempts. Trial In hospital death n (%) Survived to discharge Death in hospital Discharge disposition n (%) Hospital transfer Discharge home Median LOS (IQR) In hospital (days) In ICU (days) Intubation period (days)
Successful intubation on first attempt (n = 118)
More than one attempt for successful intubation (n = 63)
total (n = 181)
p -Value 0.11
72 (61) 46 (39)
41 (65) 22 (35)
113 (62) 68 (38)
49 (68) 23 (32)
28 (68) 13 (32)
77 (68) 36 (32)
38 (26–56) 7 (5–15) 4 (2–8)
40 (32–59) 8 (5–11) 4 (2−11)
39, (28–56) 8 (5–14) 4 (2–9)
0.45
0.34 0.32 0.64
LOS = length of stay, IQR = interquartile range, ICU = intensive care unit, ED = emergency department
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
4.3. Physicians' experience Junior residents working during the first two years in general (rotating) capacity were documented to have better success rate during first attempt intubation, compared with more senior residents or even faculty. In the large North American registry of EM resident intubations, when an initial attempt to intubate failed, 40% (385/954) of subsequent attempts were also performed by residents, with a first rescue attempt success of 80% (297/371) [5]. Based on practice in our center, we estimate that more senior residents and faculty, who supervised junior residents, were able to estimate which intubation was considered difficult and performed those themselves, resulting in a lower first-pass success rate. It is unclear how senior physicians decided exactly which patients can be intubated by junior residents. Future research should evaluate senior physicians' decision-making process in regards to trainees and intubation. 4.4. Adverse events Among 2616 intubations with direct laryngoscopy from Japan, intubation requiring multiple attempts (≥3 attempts) was associated with a higher rate of adverse events (35% vs 9%) [2]. Our study shows significantly more adverse events cases with more than one attempt for successful intubation in this study (33.3% vs 8.5%, p b 0.01). This finding was consistent with previous reports [2].
5
Thirdly, we excluded patients who died shortly after intubation in the ED, a fact that may have changed the final in-hospital mortality rate. However, the aim of this study was to examine the effect of multiple intubation attempts on long-term outcomes such as in-hospital death, and the participants who died immediately after intubation were thought to die not due to intubation technique, but initial condition they suffered from. Finally, since mortality is a multifactorial outcome, confounding factor may have been present in this study and ongoing research should investigate additional factors affecting death after intubation in the ED. 5. Conclusion We found multiple intubation attempts in the ED was not associated with increased in-hospital mortality. Further studies are needed to assess in different and in larger populations. Ethics approval Institutional Review Board of the University of Fukui. Clinical trial registration Not applicable. Prior presentations
4.5. Patient outcome We found that first pass intubation success was not associated with patients' mortality or discharge from the hospital. The concept of first pass success has been promoted as a goal in EM [15]. The outcome of patients that were admitted to the hospital after intubation in the ED has not been well documented. Even though there were higher adverse events in those with multiple intubation attempts, it is possible that patients' baseline condition leading to intubation in the ED was a much more prominent factor in determining their outcome, and the effect of an additional risk associated with several attempts to intubate in the ED was limited. The fact that more than one attempt to intubate did not result in worsening outcome in our cohort may further support the practice of offering trainees to intubate patients first under supervision. The logistic multivariant analysis suggested that use of medications during intubation was the only predictable variable associated with hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p b 0.01). However, it is possible that gravely ill patients were in a lower level of consciousness and did not need medications to allow intubation [21]. It is also possible that to save time during resuscitation with very ill patients, intubation was done promptly without spending time to draw medications. Similar to previous reports [22,23], older patients (adjusted OR 0.95, 95%CI 0.93–0.98, p b 0.01) and those with a brain injury (adjusted OR 0.15, 95%CI 0.04–0.56, p b 0.01) were less likely to be discharged home from the hospital. 4.6. Limitations There are several limitations to our study. Firstly, the sample size is relatively small and we assembled data from a single center, which may have been underpowered to detect a significant difference in mortality and may affect generalizability. However, to our knowledge, this is the first study to examine the relation between multiple intubation attempts in the ED and mortality after hospital admission. Secondly, we used retrospective data that may be subject to recollection and documentation bias. However, our practice includes multiple physicians in each intubation, resulting in conformation of data collected by multiple physicians, limiting the bias of reporting successful intubations.
This study has not been presented at a scientific meeting. Funding sources/disclosures None declared. Declaration of Competing Interest None declared. References [1] Park L, Zeng I, Brainard A. Systematic review and meta-analysis of first-pass success rates in emergency department intubation: creating a benchmark for emergency airway care. Emerg Med Australas 2017;29:40–7. [2] Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med 2012;60:749–54 [e742]. [3] Walls RM, Brown 3rd CA, Bair AE, et al. Emergency airway management: a multicenter report of 8937 emergency department intubations. J Emerg Med 2011;41: 347–54. [4] Pallin DJ, Dwyer RC, Walls RM, et al. Techniques and trends, success rates, and adverse events in emergency department pediatric intubations: a report from the National Emergency Airway Registry. Ann Emerg Med 2016;67:610–5 [e611]. [5] Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005;46:328–36. [6] Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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. Anesthesiology 2013;118: 251–70. [7] Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One 2014;9:e112779. [8] Walker RG, White LJ, Whitmore GN, et al. Evaluation of physiologic alterations during prehospital paramedic-performed rapid sequence intubation. Prehosp Emerg Care 2018:1–12. [9] Hasegawa K, Hagiwara Y, Imamura T, et al. Increased incidence of hypotension in elderly patients who underwent emergency airway management: an analysis of a multi-centre prospective observational study. Int J Emerg Med 2013;6:12. [10] Goto T, Gibo K, Hagiwara Y, et al. Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective analysis of multicentre observational data. Scand J Trauma Resusc Emerg Med 2015;23:5. [11] Hasegawa K, Hagiwara Y, Chiba T, et al. Emergency airway management in Japan: interim analysis of a multi-center prospective observational study. Resuscitation 2012; 83:428–33.
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
6
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
[12] Reich DL, Hossain S, Krol M, et al. Predictors of hypotension after induction of general anesthesia. Anesth Analg 2005;101:622–8 [table of contents]. [13] Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006;34:2355–61. [14] Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. Acad Emerg Med 1999;6:31–7. [15] Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20:71–8. [16] Kim J, Kim K, Kim T, et al. The clinical significance of a failed initial intubation attempt during emergency department resuscitation of out-of-hospital cardiac arrest patients. Resuscitation 2014;85:623–7. [17] Okubo M, Gibo K, Hagiwara Y, et al. The effectiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study. Int J Emerg Med 2017;10(1).
[18] Cook T, Mac Dougall-Davis S. Complications and failure of airway management. Br J Anaesth 2012;109:i68–85. [19] Martin LD, Mhyre JM, Shanks AM, et al. 3, 423 emergency tracheal intubations at a university hospital airway outcomes and complications. Anesthesiology 2011;114: 42–8. [20] Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations-part I. J Intensive Care Med 2007;22:157–65. [21] Smischney NJ, Beach ML, Loftus RW, et al. Ketamine/propofol admixture (ketofol) is associated with improved hemodynamics as an induction agent: a randomized, controlled trial. J Trauma Acute Care Surg 2012;73:94–101. [22] Seel RT, Corrigan JD, Dijkers MP, et al. Patient effort in traumatic brain injury inpatient rehabilitation: course and associations with age, brain injury severity, and time Postinjury. Arch Phys Med Rehabil 2015;96:S235–44. [23] Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil 2014;95:986–95 [e981].
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study Syunsuke Yamanaka, MD a,b,⁎, Ran D. Goldman, MD, FRCPC a, Tadahiro Goto, MD, MPH c, Hiroyuki Hayashi, MD b a b c
Department of Pediatrics, University of British Columbia, Vancouver, Canada Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan Graduate School of Medical Sciences, University of Fukui, Japan
a r t i c l e
i n f o
Article history: Received 26 February 2019 Received in revised form 16 June 2019 Accepted 18 June 2019 Available online xxxx
a b s t r a c t Objectives: Multiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization. Methods: We conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED. Results: Of 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p b 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24–2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93–0.98, p b 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04–0.56, p b 0.01) were independent prognostic variables. Conclusions: We found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization. © 2019 Elsevier Inc. All rights reserved.
1. Introduction Tracheal intubation is a frequent lifesaving procedure for critically ill patients in the Emergency Department (ED). Rapid and effective intubation is important but success rate of first intubation attempt in the ED setting varies significantly, ranging from 70.8 to 94.0% in a comparison of previous studies [1]. Approximately 12%–15% of patients that underwent intubation suffer from intubation-related adverse events [2-4], and multiple intubation attempts are associated with increased rate of adverse events such as vomiting, hypotension, airway injury and cardiac arrest during and immediately after intubation [5]. The number of intubation attempts has been considered by some as an index for intubation quality [6], but others argue that due to high rate of adverse events during the first intubation attempt, including cardiac
arrest [7] and abnormal physiologic reactions [8], first-pass success should not be regarded as a quality indicator. Therefore, transient adverse events associated with first pass success may not be clinically meaningful for long term outcomes. Furthermore, to our knowledge, no studies have examined the association between multiple intubation attempts in the ED, and morbidity and mortality during hospitalization. To address the existing knowledge gap, we aimed to determine whether multiple intubation attempts (two or more) in the ED are associated with an increased morbidity and mortality in patients treated in a large medical center in Japan.
2. Methods 2.1. Study design and setting
⁎ Corresponding author at: Department of Pediatrics, University of British Columbia, Vancouver, Canada. E-mail addresses: [email protected] (S. Yamanaka), [email protected] (H. Hayashi).
This study was a retrospective analysis of medical records in a general medical center in Japan. The study received the University of Fukui Hospital Institutional Review Board approval with an exemption
https://doi.org/10.1016/j.ajem.2019.06.028 0735-6757/© 2019 Elsevier Inc. All rights reserved.
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
2
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
of an informed consent. This study received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. The University of Fukui Hospital is an academic medical center certified as Level II equivalent trauma center with a census of 20,000 patient visits per year. The ED is staffed by a group of 18 emergency physicians. It is affiliated with an emergency medicine residency training program as well as a cohort of non-emergency residents. Intubations are performed by an attending physician or by a resident with direct supervision by an attending physician, a staff pediatrician, a staff neurosurgeon or a staff general surgeon. 2.2. Participants All consecutive patients who underwent emergency intubation during a 69-month period (September 1st 2010 to Apr 30th 2016), were included in the study. This period was selected based on availability of the primary author. We excluded patients who died prior to successful intubation in the ED. Patients who presented to the ED in cardiac arrest without revival were also excluded, as did patients who died shortly after intubation in the ED, and patients who were transferred to another facility from our ED following intubation. Cardiac arrest survivors with return of spontaneous circulation (ROSC) were included. 2.3. Data collection Data collection was done by the primary physician providing care for the patient, or by a physician that worked with the primary physician after each intubation in the ED, using a standardized data collection form that was designed by the Japanese Emergency Airway Network. The study methods of measurement have been previously described [2]. When data was missing, we performed post hoc interviews with the physician involved within two weeks of the encounter. We also monitored compliance with data form completion by reviewing professional billing records. Additional data related to hospitalization was obtained by the primary investigator reviewing charts in the hospital medical records department. 2.4. Measurements We collected the following variables: demographic information (patient age, sex, body mass index [BMI]), intubation related data (number of intubation attempts, time of day, day of the week, intubation method, intubation device, intubator's specialty [junior resident or senior physicians], indication for intubation, relevant medical condition, length of time the patient was intubated) and ED and hospital course (length of stay [LOS] in the hospital, in the intensive care unit [ICU], in the ED, and final disposition). Intubation method refers to medication/technique (i.e. rapid sequence intubation [RSI], sedatives without paralytics, or intubation without medications in the setting of cardiac arrest.). We considered intubation to be conducted by ‘Junior physicians’ when these were ‘junior residents’ in the first 2 years of residency (in Japan these residents rotate in different specialties and considered ‘junior’) after completing medical school (post graduate year [PGY] 1 and 2) [2]. ‘Senior physicians’ were residents committed to the specialty of EM (PGY 3,4,5), ED attending physicians, anesthesiologists and pediatricians. Indication for intubation included the following four categories [9,10]: (1) respiratory problems including internal airway obstruction, airway burn and respiratory failure such as asthma, (2) Cardiac arrest including internal or traumatic causes, (3) altered mental status due to septic shock, subarachnoid hemorrhage, neurologic disease and other internal-medicine reasons such as toxic/metabolic/infectious encephalopathy and status epilepticus, and (4) altered mental status due to traumatic causes such as multiple system injuries, traumatic shock, head injuries and face/neck injuries. Medical conditions were considered: brain-related, cardiovascular-related, multiple injuries and other
conditions (simple face/neck injury, neurologic diseases, poisoning, pulmonary diseases, sepsis and urinary tract infections). 2.5. Outcomes The primary outcome measure was mortality during hospitalization after intubation in the ED. The secondary outcome measures were disposition, hospitalization LOS, ICU LOS, and days to extubation. Mortality during hospitalization, LOS in hospital, LOS in ICU and days to extubation were determined by medical records that stored in the computerized medical records system. Days to extubation was defined as the number of days between day of intubation and the day of extubation. The primary exposure was the occurrence of multiple intubation attempts, defined as two or more intubation attempts. An intubation “attempt” was defined as a single insertion of the laryngoscope past the teeth [11]. An attempt was successful if it resulted in a tracheal tube being placed through the vocal cords, with confirmation by quantitative or colorimetric end-tidal carbon dioxide monitoring. 2.6. Statistical analysis Continuous variables were presented as mean, median and interquartile range (IQR) for LOS and intubation period. Categorical variables were presented as frequencies and percentages. Patients were dichotomized into successful intubation on first attempt, and those needing more than one attempt group. The difference in primary and secondary outcomes between groups were reported. Independent t-test or MannWhitney U test was performed for continuous variables. Chi-square and Fisher's exact test were used to examine the difference between categorical variables. We also fit multivariable logistic regression models to examine the association of number of intubation attempts in the ED and morbidity and mortality outcomes. We selected variables as a set of potential confounders based on biological plausibility and previous knowledge. These included age, sex, intubation methods, level of physician performing the first intubation and diagnostic category [2,3,12-14]. Data were analyzed using SPSS (SPSS version 25; IBM corporation, Armonk, New York, USA). All probability was two-tailed, and p value of b0.05 was considered statistically significant. The primary authors had full access to the data and were responsible for its integrity. 3. Results A total of 266 patients were intubated in the ED during the study period. Of these 81 (30.5%) were excluded as they were declared dead in the ED, 4 (1.5%) were excluded because they were transferred to another hospital after intubation and no follow-up data was available. Of the remaining 181 patients, 118 (65.2%) were intubated successfully on the initial attempt and 63 (34.8%) patients needed multiple (2 or more) intubation-attempts. Comparison between the groups is presented in Table 1. One hundred and one patients (55.8%) were males; mean age was 64.2 years (median 68, interquartile range (IQR) 56–80). The majority of patients (149, 82.3%) were intubated by a senior physician (ED attending physician, ED senior resident, anesthesiologist or pediatrician). A direct laryngoscope was the most frequently used device for first intubation attempt (165, 91.2%). Medications, including those for RSI, were used in 115 (63.5%) patients. More than half of the patients (106, 58.6%) were intubation due to internal-medicine conditions and change in consciousness, followed by traumatic causes of unconsciousness (37, 20.4%), and those that survived cardiac arrest (18, 9.9%). As diagnostic category, thirteen patients were missed and we used 161 as denominator, more than half (90, 55.2%) of patients were intubated due to brain injury, followed by cardiovascular diseases (17, 10.4%) and other conditions (44, 27%). Esophageal intubation (8, 4.4%) was the most common adverse event, followed by hypotension (5, 2.8%) and main bronchus intubation
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
3
Table 1 Patient's characteristics and comparison of successful intubation after first attempt and on subsequent attempts. Trial Sex n (%) Male Female Median age (years) (IQR) Median BMI Time of day for intubation n (%) Day (8 am–5 pm) Night (5 pm–12 pm) Overnight (midnight–8 am) Day of the week n (%) Weekday Weekend (Saturday-Sunday) Intubation method n (%) Medicationa No medications used Intubation device n (%) Laryngoscope Video laryngoscopy Level of first intubator n (%) Junior resident (PGY1 to 2) Senior resident/staff physicianb Indication for intubation n (%) Respiratory compromisec Cardiac arrest Internal disturbance of consciousness Traumatic disturbance of consciousness and face injury Diagnostic category n (%) Brain Cardiovascular Multiple injury Otherd
Successful intubation on first attempt (n = 118)
More than one attempt for successful intubation (n = 63)
Total (n = 181)
60 (50.8) 58 (49.2) 67 (56–79) 22.2
41 (65.1) 22 (34.9) 69 (55–81) 23.1
101 (55.8) 80 (44.2) 68 (56–80) 22.4
43 (36.4) 52 (44.1) 23 (19.5)
26 (41.3) 26 (41.3) 11 (17.5)
69 (38.1) 78 (43.1) 34 (18.8)
82 (69.5) 36 (30.5)
41 (65.1) 22 (34.9)
123 (68) 58 (32)
82 (69.5) 36 (30.5)
33 (52.4) 30 (47.6)
115 (63.5) 66 (36.5)
108 (91.5) 10 (8.5)
57 (90.5) 6 (9.5)
165 (91.2) 16 (8.8)
26 (22) 92 (78)
6 (9.5) 57 (90.5)
32 (17.7) 149 (82.3)
12 (10.2) 15 (12.7) 70 (59.3) 21 (17.8)
8 (12.7) 3 (4.8) 36 (57.1) 16 (25.4)
20 (11) 18 (9.9) 106 (58.6) 37 (20.4)
62 (60.2) 13 (12.6) 6 (5.8) 22 (21.4)
28 (46.7) 4 (6.7) 6 (10) 22 (36.7)
90 (55.2) 17 (10.4) 12 (7.4) 44 (27)
p -Value 0.07
0.87 0.15 0.81
0.55
0.02
0.81
0.04
0.26
0.08
IQR = interquartile range, BMI = Body Mass Index, RSI = Rapid Sequence Intubation, PGY = Post Graduate Year, ED = Emergency Department. Legend: There are significant differences in intubation methods and 1st intubator. Medication was used more in patients intubated successfully on the first attempt and the senior physician intubated more for patients requiring multiple intubations. a Defined as rapid sequence intubation, sedatives without paralytics, or paralytics without sedatives b Defined as ED attending physicians, ED senior resident (PGY 3–5), Anesthesiology and Pediatrics Staff physicians c Defined as internal airway obstruction, airway burn and respiratory failure. d Defined as simple face/neck injury, heating, lightening, neurologic diseases, poisoning, pulmonary diseases, sepsis, suffocation and urinary diseases.
(5, 2.8%). There were significantly more adverse events in multiple intubation attempts group (8.5% vs 33.3%, p b 0.01). Eighteen (9.9%) patients recovered and were admitted to our hospital after they were transferred to our ED with Cardiopulmonary Arrest (CPA). We found no significant differences in patient characteristics such as age, sex, BMI, indication for intubation, diagnostic category, time of day (shift), day of the week, or device used for first intubation attempt between the first pass intubation group and multiple intubation attempts group. We found the use of medications (defined as any use of medication including rapid sequence intubation, sedatives without paralytics, or paralytics without sedatives during the first intubation process) was associated with a higher rate of success (p = 0.02). Junior residents (PGY1 and 2) were more successful in intubating patients after one
attempt, compared to more senior physicians (p = 0.04). Morbidity and mortality variables related to patients after admission are described in Table 2. One hundred thirteen (62.4%) were discharged from the hospital. Of those, 36 (31.9%) discharged home and 77 (68.1%) were transferred to another hospital for long-term rehabilitation. Mean LOS in hospital, and ICU LOS was 44.8 days, and 9.9 days respectively. Mean intubation period was 6.6 days. There was no significant difference in hospital death rate, discharge disposition, LOS in hospital, ICU LOS, and intubation period between those successfully intubated after the first attempt or if more attempts were needed. To determine the association of intubation attempts in the ED with the mortality during hospitalization, we conducted a multivariate analysis to determine predictors of death. The odds ratio (OR) of intubation attempts for hospital death
Table 2 Adverse events and ventilation style after intubation in ED. Adverse events
Successful intubation on first attempt (n = 118)
More than one attempt for Successful Intubation (n = 63)
Total (181)
Main bronchus intubation Hypotension Esophagus intubation Teeth, lips, nose injury Vomiting (with no aspiration) Vomiting (with aspiration) Airway bleeding Sub total Ventilation style Spontaneous Forced ventilation Both
3 (2.5) 4(3.4) 0 1(0.8) 1(0.8) 0 1(0.8) 10(8.5)
2(3.2) 1(1.6) 8(12.7) 2(3.2) 1(1.6) 5(7.9) 2(3.2) 21(33.3)
5(2.8) 5(2.8) 8(4.4) 3(1.7) 2(1.1) 5(2.8) 3(1.7) 31(17.1)
11(9.7) 86(76.1) 16(14.2)
8(15.4) 36(69.2) 8(15.4)
19(11.5) 122(73.9) 24(14.5)
p-Value
b0.01 0.53
ED = Emergency Department
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
4
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
was 0.62 (95%CI 0.3–1.3, p = 0.21). In this model, use of medications during intubation was the only independent prognostic variables for hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p b 0.01). Number of attempts to achieve successful intubation was not associated with discharge disposition in our model (OR 0.77 95%CI 0.24–2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93–0.98, p b 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04–0.56, p b 0.01) were independent prognostic variables (Tables 3 and 4).
Table 4 Multivariate associations of in hospital death and discharge disposition.
In hospital death
4. Discussion Intubation is a critical procedure in maintaining patent airways and is frequently performed in the ED. First pass intubation, the successful intubation after a single attempt, has been shown to be important in reducing complications of airway management among adults and children [3,5,15-17], since multiple attempts and failed endotracheal intubations are associated with oxygen desaturation, arrhythmias, cardiac arrest, brain damage, and mortality in the ED [18-20]. Our study is the first to examine factors that may be associated with outcome of patients that were admitted to the hospital after multiple intubation attempts in the ED, using data collected from a large medical center in Japan. In our cohort, 65% of patients were successfully intubated on first attempt and 35% needed more than one attempt. We found that the use of drugs was associated with successful first attempt intubation, and that junior residents were more successful in first pass intubation, compared to more senior physicians. There were significantly more adverse events in patients with multiple intubation attempts. Using a multivariate analysis, we found that more than one intubation attempt in the ED did not adversely affect death rate or hospital discharge home. In contrast, medication use for intubation was the only significant predictive factor (p b 0.01) for patient death during hospitalization. 4.1. First pass success Multiple attempts for intubation are associated with increased adverse events such as vomiting, hypotension, airway injury and even cardiac arrest, during and immediately after intubation [5]. Based on a cohort of 1486 patients in the Japanese Emergency Airway Network, success rate of first attempt was 40–83% in different hospitals [10]. The incidence of cardiac arrest or death as adverse effect after intubation in the EDs was extremely low (0.2%) [11]. Vomiting (0.8%), dental trauma (1%), main bronchus intubation (2%), esophageal intubation with delayed recognition (3.9%) and hypotension (1.5%) were more common [10]. However, with physiologic alterations during emergency intubation, first pass intubation may not serve as a reliable predictor of quality of intubation or the patient's outcome. In one pre-hospital observational study from the US, among 134 patients with a median age of 55 years, desaturation occurred in 43%, bradycardia in 13% and hypotension in 7%. The majority (60–70%) of adverse events took place in those patients with first pass intubations [8]. In a matched case-control study
Discharge disposition
OR
Number of intubation attempts Age Sex Diagnostic category Brain Cardiovascular Multiple injuries Use of medications during intubation Experience of first intubator Number of Intubation attempts Age Sex Diagnostic category Brain Cardiovascular Multiple injury Use of medications during intubation Experience of first intubator
0.62
0.3–1.3
0.21
1.02 0.68
1–1.04 0.33–1.4
0.07 0.3
1.3 0.63 0.94
0.58–2.9 0.18–2.15 0.2–4.39
0.52 0.46 0.94
0.21 0.5 0.77
0.1–0.45 0.21–1.17 0.24–2.46
b0.01⁎ 0.11 0.66
0.95 1.02
0.93–0.98 0.35–3.1
b0.01⁎ 0.96
0.15 0.04–0.56 4.61 0.94–22.58 0.52 0.08–3.54
b0.01⁎ 0.06 0.52
0.22 0.73
95%CI
p-Value R2
Prognostic variables
0.61–8.11 0.19–3.12
0.19
0.38
0.22 0.73
OR = Odds ratio, CI = Confidence interval, R2 = Nagelkerke R square. ⁎ p b 0.01.
from South Korea, among 2403 patients (median age 64) who underwent intubation, 41 patients (1.7%) had a peri-intubation cardiac arrest, 36/41 (88%) occurred in patients with a first-attempt success. The investigators suggested that systolic hypotension shortly before intubation was the only factor associated with cardiac arrest, rather than the number of intubation attempts. The authors questioned the effect of first pass as a quality indicator since there was no relationship between multiple intubation attempts and cardiac arrest as a short-term adverse event. In terms of long-term adverse events such as inhospital death, to our knowledge, there are no previous studies and our findings failed to demonstrate that first pass success is associated with reduced in-hospital mortality or successful discharge home. We believe that multiple intubation attempts increase adverse events immediately after intubation [3,5,7,15-17]. However, its clinical impact on long-term outcomes is hard to determine. 4.2. Medication use Medication use in our cohort included the use of RSI medications, sedatives and paralytics, and was associated with successful first pass intubation. The higher success rate of RSI in our study is consistent with recent reports [5,17]. Using RSI was associated with a high level of success among EM residents [5]. In a secondary analysis of data from a multicenter prospective observational registry in 13 Japanese EDs, with 2365 patients, intubation with RSI, was independently associated with a higher success rate on first attempt [17]. Our study further strengthened the basis of RSI use in the emergency room.
Table 3 Comparison of morbidity and mortality variables with successful intubation attempts. Trial In hospital death n (%) Survived to discharge Death in hospital Discharge disposition n (%) Hospital transfer Discharge home Median LOS (IQR) In hospital (days) In ICU (days) Intubation period (days)
Successful intubation on first attempt (n = 118)
More than one attempt for successful intubation (n = 63)
total (n = 181)
p -Value 0.11
72 (61) 46 (39)
41 (65) 22 (35)
113 (62) 68 (38)
49 (68) 23 (32)
28 (68) 13 (32)
77 (68) 36 (32)
38 (26–56) 7 (5–15) 4 (2–8)
40 (32–59) 8 (5–11) 4 (2−11)
39, (28–56) 8 (5–14) 4 (2–9)
0.45
0.34 0.32 0.64
LOS = length of stay, IQR = interquartile range, ICU = intensive care unit, ED = emergency department
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
4.3. Physicians' experience Junior residents working during the first two years in general (rotating) capacity were documented to have better success rate during first attempt intubation, compared with more senior residents or even faculty. In the large North American registry of EM resident intubations, when an initial attempt to intubate failed, 40% (385/954) of subsequent attempts were also performed by residents, with a first rescue attempt success of 80% (297/371) [5]. Based on practice in our center, we estimate that more senior residents and faculty, who supervised junior residents, were able to estimate which intubation was considered difficult and performed those themselves, resulting in a lower first-pass success rate. It is unclear how senior physicians decided exactly which patients can be intubated by junior residents. Future research should evaluate senior physicians' decision-making process in regards to trainees and intubation. 4.4. Adverse events Among 2616 intubations with direct laryngoscopy from Japan, intubation requiring multiple attempts (≥3 attempts) was associated with a higher rate of adverse events (35% vs 9%) [2]. Our study shows significantly more adverse events cases with more than one attempt for successful intubation in this study (33.3% vs 8.5%, p b 0.01). This finding was consistent with previous reports [2].
5
Thirdly, we excluded patients who died shortly after intubation in the ED, a fact that may have changed the final in-hospital mortality rate. However, the aim of this study was to examine the effect of multiple intubation attempts on long-term outcomes such as in-hospital death, and the participants who died immediately after intubation were thought to die not due to intubation technique, but initial condition they suffered from. Finally, since mortality is a multifactorial outcome, confounding factor may have been present in this study and ongoing research should investigate additional factors affecting death after intubation in the ED. 5. Conclusion We found multiple intubation attempts in the ED was not associated with increased in-hospital mortality. Further studies are needed to assess in different and in larger populations. Ethics approval Institutional Review Board of the University of Fukui. Clinical trial registration Not applicable. Prior presentations
4.5. Patient outcome We found that first pass intubation success was not associated with patients' mortality or discharge from the hospital. The concept of first pass success has been promoted as a goal in EM [15]. The outcome of patients that were admitted to the hospital after intubation in the ED has not been well documented. Even though there were higher adverse events in those with multiple intubation attempts, it is possible that patients' baseline condition leading to intubation in the ED was a much more prominent factor in determining their outcome, and the effect of an additional risk associated with several attempts to intubate in the ED was limited. The fact that more than one attempt to intubate did not result in worsening outcome in our cohort may further support the practice of offering trainees to intubate patients first under supervision. The logistic multivariant analysis suggested that use of medications during intubation was the only predictable variable associated with hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p b 0.01). However, it is possible that gravely ill patients were in a lower level of consciousness and did not need medications to allow intubation [21]. It is also possible that to save time during resuscitation with very ill patients, intubation was done promptly without spending time to draw medications. Similar to previous reports [22,23], older patients (adjusted OR 0.95, 95%CI 0.93–0.98, p b 0.01) and those with a brain injury (adjusted OR 0.15, 95%CI 0.04–0.56, p b 0.01) were less likely to be discharged home from the hospital. 4.6. Limitations There are several limitations to our study. Firstly, the sample size is relatively small and we assembled data from a single center, which may have been underpowered to detect a significant difference in mortality and may affect generalizability. However, to our knowledge, this is the first study to examine the relation between multiple intubation attempts in the ED and mortality after hospital admission. Secondly, we used retrospective data that may be subject to recollection and documentation bias. However, our practice includes multiple physicians in each intubation, resulting in conformation of data collected by multiple physicians, limiting the bias of reporting successful intubations.
This study has not been presented at a scientific meeting. Funding sources/disclosures None declared. Declaration of Competing Interest None declared. References [1] Park L, Zeng I, Brainard A. Systematic review and meta-analysis of first-pass success rates in emergency department intubation: creating a benchmark for emergency airway care. Emerg Med Australas 2017;29:40–7. [2] Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med 2012;60:749–54 [e742]. [3] Walls RM, Brown 3rd CA, Bair AE, et al. Emergency airway management: a multicenter report of 8937 emergency department intubations. J Emerg Med 2011;41: 347–54. [4] Pallin DJ, Dwyer RC, Walls RM, et al. Techniques and trends, success rates, and adverse events in emergency department pediatric intubations: a report from the National Emergency Airway Registry. Ann Emerg Med 2016;67:610–5 [e611]. [5] Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005;46:328–36. [6] Apfelbaum JL, Hagberg CA, Caplan RA, et al. 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. Anesthesiology 2013;118: 251–70. [7] Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One 2014;9:e112779. [8] Walker RG, White LJ, Whitmore GN, et al. Evaluation of physiologic alterations during prehospital paramedic-performed rapid sequence intubation. Prehosp Emerg Care 2018:1–12. [9] Hasegawa K, Hagiwara Y, Imamura T, et al. Increased incidence of hypotension in elderly patients who underwent emergency airway management: an analysis of a multi-centre prospective observational study. Int J Emerg Med 2013;6:12. [10] Goto T, Gibo K, Hagiwara Y, et al. Multiple failed intubation attempts are associated with decreased success rates on the first rescue intubation in the emergency department: a retrospective analysis of multicentre observational data. Scand J Trauma Resusc Emerg Med 2015;23:5. [11] Hasegawa K, Hagiwara Y, Chiba T, et al. Emergency airway management in Japan: interim analysis of a multi-center prospective observational study. Resuscitation 2012; 83:428–33.
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028
6
S. Yamanaka et al. / American Journal of Emergency Medicine xxx (xxxx) xxx
[12] Reich DL, Hossain S, Krol M, et al. Predictors of hypotension after induction of general anesthesia. Anesth Analg 2005;101:622–8 [table of contents]. [13] Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006;34:2355–61. [14] Tayal VS, Riggs RW, Marx JA, et al. Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. Acad Emerg Med 1999;6:31–7. [15] Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20:71–8. [16] Kim J, Kim K, Kim T, et al. The clinical significance of a failed initial intubation attempt during emergency department resuscitation of out-of-hospital cardiac arrest patients. Resuscitation 2014;85:623–7. [17] Okubo M, Gibo K, Hagiwara Y, et al. The effectiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study. Int J Emerg Med 2017;10(1).
[18] Cook T, Mac Dougall-Davis S. Complications and failure of airway management. Br J Anaesth 2012;109:i68–85. [19] Martin LD, Mhyre JM, Shanks AM, et al. 3, 423 emergency tracheal intubations at a university hospital airway outcomes and complications. Anesthesiology 2011;114: 42–8. [20] Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations-part I. J Intensive Care Med 2007;22:157–65. [21] Smischney NJ, Beach ML, Loftus RW, et al. Ketamine/propofol admixture (ketofol) is associated with improved hemodynamics as an induction agent: a randomized, controlled trial. J Trauma Acute Care Surg 2012;73:94–101. [22] Seel RT, Corrigan JD, Dijkers MP, et al. Patient effort in traumatic brain injury inpatient rehabilitation: course and associations with age, brain injury severity, and time Postinjury. Arch Phys Med Rehabil 2015;96:S235–44. [23] Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. Arch Phys Med Rehabil 2014;95:986–95 [e981].
Please cite this article as: S. Yamanaka, R.D. Goldman, T. Goto, et al., Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective ..., American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2019.06.028