The Impact of Nighttime on First Pass Success During the Emergent Endotracheal Intubation of Critically Ill Patients

Abstract

Background: While numerous investigations have described worse outcomes for patients undergoing emergent procedures at night, few studies have investigated the impact of nighttime on the outcomes of emergent endotracheal intubation (EEI). We hypothesized that for patients requiring EEI at night, the outcome of first pass success would be lower as compared to during the day. Methods: We performed a retrospective cohort study of all patients admitted to our institution between January 1st, 2016 and July 17st, 2019 who underwent EEI outside of an emergency department or operating room. Nighttime was defined as between 7:00 pm and 6:59 am. The primary outcome was the rate of first pass success. Logistic regression was utilized with adjustment for demographic, morbidity and procedure related covariables. Results: The final examined cohort included 1,674 EEI during the day and 1,229 EEI at night. The unadjusted rate of first pass success was not different between the day and night (77.5% vs. 74.6%, unadjusted odds ratio (OR): 0.85; 95% confidence interval (CI): 0.72, 1.0; P = 0.073 though following adjustment for prespecified covariables the odds of first pass success was lower at night (adjusted OR: 0.83, 95% CI: 0.69, 0.99; P = 0.042. Obesity was found to be an effect modifier on first pass success rate for day vs. night intubations. In obese patients, nighttime intubations had significantly lower odds of first pass success (adjusted OR: 0.71, 95% CI: 0.52, 0.98; P = 0.037). Discussion: After adjustment for patient and procedure related factors, we have found that the odds of first pass success is lower at night as compared to the day. This finding was, to some degree, driven by obesity which was found to be a significant effect modifier in this relationship.

Implementation and Outcomes of a Difficult Airway Code Team Composed of Anesthesiologists in a Korean Tertiary Hospital: A Retrospective Analysis of a Prospective Registry

“…In contrast to other studies, 10 11 the AC teams were activated more frequently outside working hours than during working hours in our study, which may be attributed to a lack of supervising staff in the wards and ICU on weekends, holidays, and nights. Because emergency intubation performed by primary physicians outside of working hours is associated with a lower success rate and higher complication rate compared to that performed during working hours, 12 13 it is highly recommended that the AC team provides continuous coverage.…”

Fatigue amongst anaesthesiology and intensive care trainees in Europe

“…Communication and collaboration with clinical staff or patients may be affected, further contributing to the risk of clinical error. Psychomotor skills are affected; orotracheal intubation has lower odds of first pass success if performed at night compared with the day, 21 and inadvertent dural puncture is more frequent 22 …”

“…20 Communication and collaboration with clinical staff or patients may be affected, further contributing to the risk of clinical error. Psychomotor skills are affected; orotracheal intubation has lower odds of first pass success if performed at night compared with the day, 21 and inadvertent dural puncture is more frequent. 22 Most hospitals have no rest facilities and the few that are available often remain unused, as many trainees prefer to return home than rest after a shift.…”

Fatigue among anaesthesiologists in Europe

“…Skills, like successful intubation, are impaired at night, and communication and collaboration suffer as fatigue sets in. 27,28 Fatigue-induced deterioration in vigilance, situational awareness and decisionmaking may go unnoticed to its insidious nature.…”