Adverse Tracheal Intubation-Associated Events in Pediatric Patients at Nonspecialist Centers: A Multicenter Prospective Observational Study

Objectives: In tertiary care PICUs, adverse tracheal intubation-associated events occur frequently (20%; severe tracheal intubation-associated events in 3-6.5%). However, pediatric patients often present to nonspecialist centers and require intubation by local teams. The rate of tracheal intubation-associated events is not well studied in this setting. We hypothesized that the rate of tracheal intubation-associated events would be higher in nonspecialist centers. Design: Prospective observational study. Setting: We conducted a multicenter study covering 47 local hospitals in the North Thames and East Anglia region of the United Kingdom. Patients: All intubated children transported by the Children's Acute Transport Service from June 2016 to May 2018. Interventions: None. Measurements and Main Results: Data were available in 1,051 of 1,237 eligible patients (85%). The overall rate of tracheal intubation-associated events was 22.7%, with severe tracheal intubation- associated events occurring in 13.8%. Younger, small-for-age patients and those with difficult airways had a higher rate of complications. Children with comorbidities and difficult airways were found to have increased severe tracheal intubation-associated events. The most common tracheal intubation-associated events were endobronchial intubation (6.2%), hypotension (5.4%), and bradycardia (4.2%). In multivariate analysis, independent predictors of tracheal intubation-associated events were number of intubation attempts (odds ratio for > 4 attempts compared with a single attempt 19.1; 95% CI, 5.9-61.4) and the specialty of the intubator (emergency medicine compared with anesthesiologists odds ratio 6.9; 95% CI, 1.1-41.4). Conclusions: Tracheal intubation-associated events are common in critically ill pediatric patients who present to nonspecialist centers. The rate of severe tracheal intubation-associated events is much higher in these centers as compared with the PICU setting. There should be a greater focus on improving the safety of intubations occurring in nonspecialist centers.