Neonatal Intubation Practice and Outcomes: An International Registry Study

Abstract

for the NEAR4NEOS Investigators BACKGROUND AND OBJECTIVES: Neonatal tracheal intubation is a critical but potentially dangerous procedure. We sought to characterize intubation practice and outcomes in the NICU and delivery room (DR) settings and to identify potentially modifiable factors to improve neonatal intubation safety. METHODS:We developed the National Emergency Airway Registry for Neonates and collected standardized data for patients, providers, practices, and outcomes of neonatal intubation. Safety outcomes included adverse tracheal intubation-associated events (TIAEs) and severe oxygen desaturation (≥20% decline in oxygen saturation). We examined the relationship between intubation characteristics and adverse events with univariable tests and multivariable logistic regression. RESULTS:We captured 2009 NICU intubations and 598 DR intubations from 10 centers. Pediatric residents attempted 15% of NICU and 2% of DR intubations. In the NICU, the first attempt success rate was 49%, adverse TIAE rate was 18%, and severe desaturation rate was 48%. In the DR, 46% of intubations were successful on the first attempt, with 17% TIAE rate and 31% severe desaturation rate. Site-specific TIAE rates ranged from 9% to 50% (P < .001), and severe desaturation rates ranged from 29% to 69% (P = .001). Practices independently associated with reduced TIAEs in the NICU included video laryngoscope (adjusted odds ratio 0.46, 95% confidence interval 0.28-0.73) and paralytic premedication (adjusted odds ratio 0.38, 95% confidence interval 0.25-0.57). CONCLUSIONS:We implemented a novel multisite neonatal intubation registry and identified potentially modifiable factors associated with adverse events. Our results will inform future interventional studies to improve neonatal intubation safety. abstract NIH WHAT'S KNOWN ON THIS SUBJECT: Endotracheal intubation is a critical skill in neonatology but is less frequently performed than in previous years because of changes in neonatal practice. Little is known about the current practice and safety outcomes of neonatal intubation in the academic setting. WHAT THIS STUDY ADDS:Pediatric residents rarely perform neonatal intubation. Only half of first intubation attempts are successful, and adverse events and severe oxygen desaturation are common. Paralytic premedication and video laryngoscopy are associated with decreased adverse events in the NICU.

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

“…While the definition of adverse TIAEs does not include hypoxemia, these are often reported together. Current evidence suggests 1. adverse TIAEs and hypoxemia are common in airway management in the pediatric ICUs, Emergency Department, and neonatal ICUs, 2. patient, clinician, and practice factors are associated with the occurrence of these adverse events, and 3. interdisciplinary quality improvement has helped reduce these events . Pediatric anesthesiologists can partner with nonanesthesiologists to improve the safety of airway management in these clinical locations.…”

“…In neonatal ICUs (NICU) and the delivery room (DR), first‐attempt success was 49% in NICU, 46% in the DR, and the course success was 96% in NICU and 95% in DR . Tracheal intubation was associated with adverse TIAEs in 18% (NICU) and 17% (DR).…”

Adequate analgesia and sedation should be given to neonates during non‐emergency endotracheal intubation

“…This practice is an essential ethical requirement and best practice, according to the available scientific evidence. However, premedication practices for neonatal endotracheal intubation differ widely and many infants are still being intubated without any analgesia or sedation . The reasons why many neonatologists do not use appropriate premedication have been inadequately evaluated.…”

“…Second, neonatologists may have been reluctant to change practices they feel work well, despite clinical evidence. This area is only just being researched and a study of neonatologists' performance during endotracheal intubations reported a low success rate of 49% at the first attempt and adverse events in up to 50% of intubations . Furthermore, it has been shown that premedication, especially neuromuscular blocking agents, improves success rates and patient safety .…”

“…While this concern cannot be entirely resolved, it may be alleviated by the evidence and recommendations in the current clinical guidelines. Mortality associated with endotracheal intubation is less than two per 1000 intubations and there is no evidence of an association between mortality and premedication . Implementing hospital‐specific standard operating procedures, ideally embedded in quality improvement initiatives, may reassure clinicians and promote appropriate premedication for endotracheal intubation in neonates.…”