Elsevier

The Journal of Pediatrics

Volume 168, January 2016, Pages 62-66.e6
The Journal of Pediatrics

Original Article
Endotracheal Intubation in Neonates: A Prospective Study of Adverse Safety Events in 162 Infants

Portions of this study have been presented as abstracts and posters at the Vermont Oxford Network Quality Congress, Chicago, IL, October 31-November 2, 2014, and the meeting of the Pediatric Academic Societies, San Diego, CA, April 25-28, 2015.
https://doi.org/10.1016/j.jpeds.2015.09.077Get rights and content

Objective

To determine the rate of adverse events associated with endotracheal intubation in newborns and modifiable factors contributing to these events.

Study design

We conducted a prospective, observational study in a 100-bed, academic, level IV neonatal intensive care unit from September 2013 through June 2014. We collected data on intubations using standardized data collection instruments with validation by medical record review. Intubations in the delivery or operating rooms were excluded. The primary outcome was an intubation with any adverse event. Adverse events were defined and tracked prospectively as nonsevere or severe. We measured clinical variables including number of attempts to successful intubation and intubation urgency (elective, urgent, or emergent). We used logistic regression models to estimate the association of these variables with adverse events.

Results

During the study period, 304 intubations occurred in 178 infants. Data were available for 273 intubations (90%) in 162 patients. Adverse events occurred in 107 (39%) intubations with nonsevere and severe events in 96 (35%) and 24 (8.8%) intubations, respectively. Increasing number of intubation attempts (OR 2.1, 95% CI, 1.6-2.6) and emergent intubations (OR 4.7, 95% CI, 1.7-13) were predictors of adverse events. The primary cause of emergent intubations was unplanned extubation (62%).

Conclusions

Adverse events are common in the neonatal intensive care unit, occurring in 4 of 10 intubations. The odds of an adverse event doubled with increasing number of attempts and quadrupled in the emergent setting. Quality improvement efforts to address these factors are needed to improve patient safety.

Section snippets

Methods

We conducted a prospective, observational study in the 100-bed, academic, level IV (regional) NICU of the Vanderbilt University Medical Center. Endotracheal intubations are performed by pediatric residents, neonatal fellows, neonatal nurse practitioners/hospitalists, neonatologists, anesthesiologists, and otolaryngologists. Premedication for intubation was commonly used and consisted of an opiate and a benzodiazepine, though no formal protocol existed at the time of this study. The Vanderbilt

Results

During the 10-month study period, clinicians performed 304 endotracheal intubation encounters in 178 infants, an average of 1 intubation encounter per day. All intubations were performed orally, and no intubation encounter required more than 1 course. Adverse event data were available for 273 intubation encounters (90%) in 162 patients. One or more adverse events occurred in 107 of 273 intubations (39%). Nonsevere and severe events occurred in 96 (35%) and 24 (8.8%) intubations, respectively (

Discussion

We report that adverse events associated with endotracheal intubation in a large academic NICU were common, occurring in 4 of 10 intubations. Emergent intubations are associated with more than 4-fold increased odds of an adverse event. The most common cause for an emergent intubation in our cohort was unplanned extubation. In addition, higher numbers of intubation attempts were associated with increasing rates of adverse events, with each additional attempt doubling the odds of an adverse event.

References (22)

  • B. Lane et al.

    Duration of intubation attempts during neonatal resuscitation

    J Pediatr

    (2004)
  • T.A. Leone et al.

    Neonatal intubation: success of pediatric trainees

    J Pediatr

    (2005)
  • R. Kaushal et al.

    Medication errors and adverse drug events in pediatric inpatients

    JAMA

    (2001)
  • C. Snijders et al.

    Incidents and errors in neonatal intensive care: a review of the literature

    Arch Dis Child Fetal Neonatal Ed

    (2007)
  • D.M. Needham et al.

    A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS)

    Crit Care Med

    (2004)
  • R. Rivera et al.

    Complications of endotracheal intubation and mechanical ventilation in infants and children

    Crit Care Med

    (1992)
  • J.J. Stambouly et al.

    Complications of care in a pediatric intensive care unit: a prospective study

    Intensive Care Med

    (1996)
  • J.L. Skapik et al.

    Pediatric safety incidents from an intensive care reporting system

    J Patient Saf

    (2009)
  • C.L. Carroll et al.

    Emergent endotracheal intubations in children: be careful if it's late when you intubate

    Pediatr Crit Care Med

    (2010)
  • A. Nishisaki et al.

    Characterization of tracheal intubation process of care and safety outcomes in a tertiary pediatric intensive care unit

    Pediatr Crit Care Med

    (2012)
  • A. Nishisaki et al.

    A National Emergency Airway Registry for children: landscape of tracheal intubation in 15 PICUs

    Crit Care Med

    (2013)
  • Cited by (0)

    Use of the Research Electronic Data Capture program was supported by National Center for Advancing Translational Sciences/National Institutes of Health (NIH; UL1 TR000445). L.H. was supported by the NIH (5T32HD068256-02) and the John and Leslie Hooper Neonatal-Perinatal Endowment Fund. The authors declare no conflicts of interest.

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