DEATH AND OTHER COMPLICATIONS OF EMERGENCY AIRWAY MANAGEMENT IN CRITICALLY ILL ADULTS - A PROSPECTIVE INVESTIGATION OF 297 TRACHEAL INTUBATIONS

Background: Hospitalized patients outside of the operating room freque ntly require emergency airway management, This study investigates comp lications of emergency airway management in critically ill adults, inc luding: (1) the incidence of difficult and failed intubation; (2) the frequency of esophageal intubation; (3) the incidence of pneumothorax and pulmonary aspiration; (4) the hemodynamic consequences of emergent intubation, including death, during and immediately following intubat ion; and (5) the relationship, if any, between the occurrence of compl ications and supervision of the intubation by an attending physician. Methods: Data were collected on consecutive tracheal intubations carri ed out by the intensive care unit team over a 10-month period, Non-ane sthesia residents were supervised by anesthesia residents, critical ca re attending physicians, or anesthesia attending physicians. Results: Two hundred ninety-seven consecutive intubations were carried out in 2 38 adult patients. Translaryngeal tracheal intubation was accomplished in all patients. Intubation was difficult in 8% of cases (requiring m ore than two attempts at laryngoscopy by a physician skilled in airway management). Esophageal intubation occurred in 25 (8%) of the attempt s but all were recognized before any adverse sequelae resulted. New in filtrates suggestive of pulmonary aspiration were present on chest rad iograph after 4% of intubations. Seven patients (3%) died during or wi thin 30 min of the procedure. Five of the seven patients had systemic hypotension (systolic blood pressure less than or equal to 90 mmHg), a nd four of the five were receiving vasopressors to support systolic bl ood pressure. Patients with systolic hypotension were more likely to d ie after intubation than were normotensive patients (P < 0.001). There was no relationship between supervision by an attending physician and the occurrence of complications. Conclusions: In critically ill patie nts, emergency tracheal intubation is associated with a significant fr equency of major complications. In this study, complications were not increased when intubations were accomplished without the supervision o f an attending physician as long as the intubation was carried out or supervised by an individual skilled in airway management. Mortality as sociated with emergent tracheal intubation is highest in patients who are hemodynamically unstable and receiving vasopressor therapy before intubation,