Failed endotracheal intubation and adverse outcomes among extremely low birth weight infants

Abstract

OBJECTIVETo quantify the importance of successful endotracheal intubation on the first attempt among extremely low birth weight (ELBW) infants who require resuscitation after delivery.STUDY DESIGNA retrospective chart review was conducted for all ELBW infants ≤1000 g born between January 2007 and May 2014 at a level IV neonatal intensive care unit. Infants were included if intubation was attempted during the first five minutes of life, or if intubation was attempted during the first 10 minutes of life with heart rate < 100. The primary outcome was death or neurodevelopmental impairment. The association between successful intubation on the first attempt and the primary outcome was assessed using multivariable logistic regression with adjustment for birth weight, gestational age, gender, and antenatal steroids.RESULTSThe study sample included 88 ELBW infants. Forty-percent were intubated on the first attempt and 60% required multiple intubation attempts. Death or neurodevelopmental impairment occurred in 29% of infants intubated on the first attempt, compared to 53% of infants that required multiple attempts, adjusted odds ratio 0.4 (95% confidence interval 0.1 - 1.0), p < 0.05.CONCLUSIONSuccessful intubation on the first attempt is associated with improved neurodevelopmental outcomes among ELBW infants. This study confirms the importance of rapid establishment of a stable airway in ELBW infants requiring resuscitation after birth and has implications for personnel selection and role assignment in the delivery room.

Normal and difficult airways in children: “What’s New”—Current evidence

“…The effect of these immediate airway management outcomes on NICU outcomes or neurodevelopmental impact has not been reported on a large scale. One small single‐center retrospective study (n = 88) reports a strong association between first laryngoscopy attempt success within 10 minutes of life and better neurodevelopmental outcomes among extremely very low birthweight infants (ie, birthweight ≤ 1000g): death or neurodevelopmental impairment 29% in infants with first‐attempt success versus 53% in infants with multiple laryngoscopy attempts, unadjusted odds ratio 0.4, 95% CI 0.1‐1.0, P < .05 …”

Time without ventilation during intubation in neonates as a patient-centred measure of performance

“…Moreover, the average time to determine ETT placement was much longer for failed attempts, 61 (47-85 ), than for successful attempts, 47 (37-55 [28-160]). The median time to recommence ventilation after intubation was similar for successful attempts, 5(4-8 [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]), and withdrawn attempts, 5 (3-5 [2-38]), but much longer for failed attempts, 28 (17-56 [8-223]). …”

Delivery Room Quality Improvement Project Improved Compliance with Best Practices for a Community NICU

“…Another recent retrospective chart looked at 88 extremely low birth weight infants that were intubated in the delivery room during the first ten minutes after birth. Those infants who needed more than one attempt at intubation for successful placement of the endotracheal tube had a greater likelihood of death or neurodevelopmental impairment15. A randomized control trial from 2006 showed that successful intubations with fewer attempts occur more often in infants who received premedication which included a paralytic agent16.…”