Failed Attempts at Intubation Associated With More Adverse Events

Failure to achieve first-attempt success during intubation using a video laryngoscope is associated with higher odds of adverse events in the ICU, according to a recent study.

First-attempt success should be the goal of emergency airway management, regardless of location or device used, the researchers said.

“First-attempt success isn’t a patient-centered outcome, but it is good for measuring adverse events,” said Cameron Hypes, MD, MPH, of the University of Arizona College of Medicine, in Tucson. Dr. Hypes presented the research at the 2016 annual meeting of the Society for Airway Management. “This rings true in different environments, not just the ICU.”

The observational study investigated 905 patients intubated with a video laryngoscope in the University of Arizona Medical Center’s ICU between Jan. 1, 2012, and Jan. 1, 2016. Of these, first-attempt success occurred in 739 patients (82%), and of these, there was an adverse event in 146 (20%).

More than one attempt was associated with six times the odds of at least one adverse event.

At two attempts, 62% of patients had one or more complications. By three attempts, 72% experienced complications. Likewise, four attempts meant complication rates of 83%, and five meant 100%.

“In the past, we’ve seen that more than two attempts in the ICU is associated with increased complications, and this demonstrates that even a second attempt increases that,” Dr. Hypes said. “Requiring more than even one attempt is still associated with increased odds of adverse events.”

As part of the airway quality improvement program at the University of Arizona, each operator must fill out a form after an intubation that documents information about the operator, patient, procedure and complications.

The majority of operators were in their fourth postgraduate year (first year of fellowship), with the highest success rates recorded in the fourth and fifth years.

“Not surprisingly, more experienced operators had higher first-attempt success rates,” he said. “And with the first-attempt failures, we saw more difficult airway characteristics, such as blood in the airway or obesity, which is also not surprising.”

At the University of Arizona, the research team is pushing against the idea that the first attempt is a free attempt. Rather, they’re advocating for patient optimization before the first attempt ever occurs.

“When we talk about first-pass success, it’s not, ‘Keep going until you get it,’” said John Sakles, MD, of the University of Arizona, a co-author of the study and moderator of the poster presentations.

“Optimize the hemodynamic and oxygenation status of the patient, position the patient properly and choose the right equipment for the clinical situation, so when you go in, you have a high chance of success on your first attempt,” he said. “That’s a big distinction we need to make.”