Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival

Abstract

Importance: Tracheal intubation is common during pediatric in-hospital cardiac arrest, although the relationship between intubation during cardiac arrest and outcomes is unknown.

Objective: To determine if intubation during pediatric in-hospital cardiac arrest is associated with improved outcomes.

Design, setting, and participants: Observational study of data from United States hospitals in the Get With The Guidelines-Resuscitation registry. Pediatric patients (<18 years) with index in-hospital cardiac arrest between January 2000 and December 2014 were included. Patients who were receiving assisted ventilation, had an invasive airway in place, or both at the time chest compressions were initiated were excluded.

Exposures: Tracheal intubation during cardiac arrest .

Main outcomes and measures: The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation and neurologic outcome. A favorable neurologic outcome was defined as a score of 1 to 2 on the pediatric cerebral performance category score. Patients being intubated at any given minute were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

Results: The study included 2294 patients; 1308 (57%) were male, and all age groups were represented (median age, 7 months [25th-75th percentiles, 21 days, 4 years]). Of the 2294 included patients, 1555 (68%) were intubated during the cardiac arrest. In the propensity score-matched cohort (n = 2270), survival was lower in those intubated compared with those not intubated (411/1135 [36%] vs 460/1135 [41%]; risk ratio [RR], 0.89 [95% CI, 0.81-0.99]; P = .03). There was no significant difference in return of spontaneous circulation (770/1135 [68%] vs 771/1135 [68%]; RR, 1.00 [95% CI, 0.95-1.06]; P = .96) or favorable neurologic outcome (185/987 [19%] vs 211/983 [21%]; RR, 0.87 [95% CI, 0.75-1.02]; P = .08) between those intubated and not intubated. The association between intubation and decreased survival was observed in the majority of the sensitivity and subgroup analyses, including when accounting for missing data and in a subgroup of patients with a pulse at the beginning of the event.

Conclusions and relevance: Among pediatric patients with in-hospital cardiac arrest, tracheal intubation during cardiac arrest compared with no intubation was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding, these findings do not support the current emphasis on early tracheal intubation for pediatric in-hospital cardiac arrest.

Figure 1.

Patient Selection for Study of Tracheal Intubation During Pediatric Cardiac Arrest GWTG-R, Get With The Guidelines-Resuscitation; IHCA indicates in-hospital cardiac arrest; NICU, neonatal intensive care unit.

Figure 2.

Distribution of Time to Intubation Distribution of time from start of chest compression to documented successful intubation during cardiopulmonary resuscitation (CPR) in those intubated. Of the 1555 patients (68%) intubated during the CPR event, the median time to intubation from start of chest compressions was 5 minutes (25th-75th percentiles, 2–11). Data on time to intubation were recorded in whole minutes. Time to intubation of 0 minutes indicates that intubation was performed in the same whole minute as the start of chest compressions.

Figure 3.

Main and Sensitivity or Secondary Analyses According to Outcome Unadjusted and adjusted analyses as well as sensitivity analyses and the subgroups of pulseless patients and patients with a pulse at the beginning of the event for the primary outcome survival to hospital discharge and the secondary outcomes return of spontaneous circulation (ROSC) and favorable neurologic outcome at hospital discharge. ROSC was defined as no further need for chest compressions that was sustained for greater than 20 minutes. Neurologic outcome was determined using the pediatric cerebral performance category (PCPC) score, for which a PCPC score of 1 indicates no neurologic deficit; 2, mild cerebral disability; 3, moderate cerebral disability; 4, severe cerebral disability; 5, coma or vegetative state; and 6, brain death. A PCPC score of 1 and 2 was considered a favorable neurologic outcome, and a PCPC score of 3 to 6 or death was considered a poor neurologic outcome. The “main adjusted” analysis refers to the multivariable time-dependent propensity score-matched analysis. CPB indicates cardiopulmonary bypass; CPR, cardiopulmonary resuscitation.