Short Attention Span Summary
Wait on the ETT
Last month we covered an article showing kids did worse with early intubation during arrest. This study of in-hospital arrest found the same held true in adults. The most important outcome, survival with a good neurological outcome, was better in patients not intubated in the first 15 minutes of arrest. The NNT was 33, the “treatment” being – not intubating them. Overall survival and ROSC were also lower in patients who were intubated. The methods of this huge study were complex. For each minute of arrest, up to 15 minutes, those who were not intubated were propensity matched to those who were and outcomes were calculated. But why did they do worse? Did intubation cause a pause in compressions or delay in other aspects of resuscitation? Did intubated patients get overzealous bagging with breath stacking? It is hard to know. Of course, this was observational and subject to confounding despite propensity matching.
Early intubation in adult in-hospital arrest was associated with poorer outcomes and worse neurologically-intact survival. Emphasize high quality CPR and defibrillation, while deemphasizing early ETT placement.
JAMA. 2017 Jan 24. doi: 10.1001/jama.2016.20165. [Epub ahead of print]
1Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark2Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark3Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
2Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark.
3Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
4Division of Cardiology, Department of Medicine, VA Eastern Colorado Health Care System, Denver6Now with Minneapolis Heart Institute, Minneapolis, Minnesota.
5Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, England.
6University of Bristol, Bristol, England9Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, England.
7Institute of Public Health, Charité-Universitätsmedizin Berlin, Berlin, Germany.
8Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts11Division of Pulmonary and Critical Care Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting.
To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.
Design, Setting, and Participants:
Observational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines-Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) 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.
Tracheal intubation during cardiac arrest.
Main Outcomes and Measures:
The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome.
The propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95% CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.
Conclusions and Relevance:
Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.
PMID: 28118660 [PubMed – as supplied by publisher]