Cardiac Arrests Associated With Tracheal Intubations in PICUs: A Multicenter Cohort Study

Objectives: To determine the incidence and epidemiologic characteristics of cardiac arrests among tracheal intubations in PICUs. Design: Retrospective cohort study of prospectively collected data. Setting: Twenty-five diverse PICUs. Patients: Critically ill children requiring tracheal intubation in PICUs. Interventions: Tracheal intubation quality improvement data were prospectively collected for all initial tracheal intubations in 25 PICUs from July 2010 to March 2014 using National Emergency Airway Registry for Children registry. Measurements and Main Results: Tracheal intubation associated cardiac arrest was defined as chest compressions more than 1 minute occurring during tracheal intubation or within 20 minutes after tracheal intubation. A total of 5,232 pediatric tracheal intubations were evaluated. Tracheal intubation associated cardiac arrest was reported in 87 (1.7%). Patient factors (demographics and indications for tracheal intubation), provider factors (discipline and training level), and practice factors (tracheal intubation method and use of neuromuscular blockade) were recorded. Hemodynamic instability and oxygenation failure as tracheal intubation indications were associated with cardiac arrests (adjusted odds ratio, 6.3; 95% CI, 3.9-10.3; and adjusted odds ratio, 4.3; 95% CI, 2.6-6.9, respectively). History of difficult airway and cardiac disease were also associated with cardiac arrests (adjusted odds ratio, 2.1; 95% CI, 1.2-3.5; and adjusted odds ratio, 2.1; 95% CI, 1.2-3.9, respectively). Provider and practice factors were not associated with cardiac arrests, and provider factors did not modify the effect of patient factors on cardiac arrests. Conclusions: Tracheal intubation associated cardiac arrests occurred during 1.7% of PICU tracheal intubations. Tracheal intubation associated cardiac arrests were much more common with tracheal intubations when the child had acute hemodynamic instability or oxygen failure and when the child had a history of difficult airway or cardiac disease.