Background: Cardiac arrest is an under-recognized complication of emergent endotracheal intubation (ETI) within the pediatric population. No studies evaluate risk factors for peri-intubation cardiac arrest (PICA) in a pediatric emergency department (ED) specific setting. Pediatric intensive care unit (PICU) and adult ED studies suggest hypoxia, cardiac disease, and hemodynamic instability predict PICA in patients undergoing emergent ETI. This study identifies risk factors for PICA among patients undergoing emergent ETI in a pediatric ED.
Methods: We conducted a retrospective case-control study of children under 18 years of age who underwent emergent ETI in our pediatric ED. Cases were children with PICA within 20 minutes of ETI. Controls were randomly selected children without PICA following ETI. We excluded patients intubated out-of-ED and those receiving active chest compressions during the initial ETI attempt. We analyzed potential risk factors based upon published data and physiologic plausibility, including hemodynamic factors (age-adjusted systolic blood pressure (SBP) and diastolic blood pressure (DBP), capillary refill time, fluid resuscitation), patient characteristics (pulse oximetry, co-morbidities, body mass index), and intubating conditions (type of sedative or paralytic, number of attempts, time of day, intubating specialty, level of training). Characteristics that differed between cases and controls were entered into regression analysis.
Results: Of the 546 eligible, 3.9% or 21 total patients incurred PICA, with return of spontaneous circulation (ROSC) in 76.2% and survival to discharge in 57.1%. Cases were more likely to have delayed capillary refill, abnormal age-adjusted SBP, abnormal age-adjusted DBP, hypoxia, a higher number of intubation attempts, and pulmonary disease when compared with controls on univariate analysis. Following logistic regression, hypoxia (42.9% vs 2.4%, OR 31.4, 95%CI 3.0-324.5, p<0.01), delayed capillary refill (85.7% vs 22.6%, OR 9.3, 95%CI 1.3-65.3, p=0.02), and number of intubation attempts (mean 2.6 vs 1.3, OR 4.6, 95%CI 1.7-12.7, p<0.01) were independent factors associated with PICA.
Conclusion: Hypoxia, prolonged capillary refill time, and number of intubation attempts were independently associated with PICA in our pediatric ED.