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Original Investigation
Caring for the Critically Ill Patient
November 1, 2016

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

Author Affiliations
  • 1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 2Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
  • 3Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
  • 4Division of Cardiac Critical Care, Department of Pediatrics, Medical City Children's Hospital, Dallas, Texas
  • 5Department of Anesthesiology and Critical Care, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 6Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 7Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
  • 8Department of Emergency Medicine, University of Pennsylvania, Philadelphia
  • 9Now with the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 10Institute of Public Health, Charité–Universitätsmedizin Berlin, Berlin, Germany
  • 11Department of Medicine, Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JAMA. 2016;316(17):1786-1797. doi:10.1001/jama.2016.14486
Key Points

Question  Is tracheal intubation during pediatric in-hospital cardiac arrest associated with a difference in survival?

Findings  In this observational study including 2270 matched patients, tracheal intubation during pediatric cardiac arrest was significantly associated with decreased survival to hospital discharge (36% for those intubated compared with 41% for those not intubated).

Meaning  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.

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.

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