Background and objective: Rapid sequence intubation (RSI), or the delivery of sedative and paralytic medications in rapid succession, is the reference standard for definitive airway management in emergency medicine. RSI is thought to be an effective and safe procedure for the majority of emergency department (ED) patients, but published research is limited for RSI in pediatric emergency patients. Our study's objective was, using video review, to estimate the true frequency of first attempt success and adverse effects of RSI for children intubated in a pediatric ED.
Methods: We conducted an observational study of a 12-month sample of patients managed in the ED of a tertiary care pediatric institution. All children undergoing RSI in the ED were eligible. Video review was the primary source for all data, where possible. Three investigators independently collected data from a third of subject video and medical records. The primary outcome measure was the number of patients successfully intubated on the first attempt at laryngoscopy. The secondary outcome was the number of patients with at least one adverse effect during RSI, including episodes of physiologic deterioration. We collected additional data elements from the RSI process and intubating providers, including physician type and time data. The unit of analysis was the patient. We analyzed first attempt success by intubating physician type and conducted an analysis of inter-rater reliability for 10% of subjects, whose videos were reviewed independently by a second investigator.
Results: We obtained complete records for 114 of 123 (93%) children who underwent RSI from March 2009 through April 2010. Median age was 2.4 years (IQR 0.4, 10.1) and 78% were medical (non-trauma) resuscitations. The first attempt at laryngoscopy was successful for 59 subjects (52%, 95% CI 43%, 61%); 30 required three or more attempts for successful intubation, with a maximum of 9 attempts. RSI was ultimately successful for all 114 subjects, and no subject required a surgical airway. Seventy subjects (61%, 95% CI 52%, 70%) suffered at least one adverse effect during RSI. Thirty-eight patients (33%) had at least one episode of oxyhemoglobin desaturation (<90%). Two patients required CPR for physiologic deterioration and loss of pulses during RSI; both had return of spontaneous circulation after successful intubation on the third attempt and survived to hospital discharge. No study subject died in the ED; 5 died during hospitalization. The median duration of the RSI process (first RSI sedative to insertion of final ETT) was 3.2 minutes (1.9, 7.5). First attempt success varied by physician type, with pediatric residents successful on 35% of first attempts (n = 48) and attending level providers successful on 89% of first attempts (n = 18; p < 0.001 for difference). After controlling for patient age and other covariates, attending providers were 10 times more likely to be successful on the first attempt that all trainees combined.
Conclusions: Video review revealed that first attempt failure and adverse effects were much more common than previously reported. Video review uniquely allowed a detailed description of the RSI process.