The importance of first pass success

February 20, 2013 by  
Filed under All Updates, EMS, ICU, Resus, Trauma

mv-vl-iconA large single-centre study in an academic tertiary care center emergency department (where residents perform most of the intubations) examined 1,828 orotracheal intubations, of which 1,333 were intubated successfully on the first attempt (72.9%).
Adverse events (AE) captured were oesophageal intubation, oxygen desaturation, witnessed aspiration, mainstem intubation, accidental extubation, cuff leak, dental trauma, laryngospasm, pneumothorax, hypotension, dysrhythmia, and cardiac arrest.

When the first pass was successful, the incidence of AEs was 14.2%. More than one attempt was associated with significantly more AEs. Patients requiring two attempts had 33% more AEs (47.2%) and as the number of attempts increased, so did the risk of AEs, with the largest increase in AEs occurring between an unsuccessful first attempt and the second intubation attempt.

This is a powerful argument in favour of optimising first pass success. In the prehospital service I work for, We like to include this in a ‘first pass, no desat, no hypotension’ package that includes team simulation training, pre-intubation briefing, checklist use, optimisation of position, ketamine induction (and avoidance of propofol), apnoeic oxygenation, bougie use, bimanual laryngoscopy, and waveform capnography.

The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department
Academic Emergency Medicine 2013;20(1):71–78, Free Full Text


Objectives The goal of this study was to determine the association of first pass success with the incidence of adverse events (AEs) during emergency department (ED) intubations.

Methods This was a retrospective analysis of prospectively collected continuous quality improvement data based on orotracheal intubations performed in an academic ED over a 4-year period. Following each intubation, the operator completed a data form regarding multiple aspects of the intubation, including patient and operator characteristics, method of intubation, device used, the number of attempts required, and AEs. Numerous AEs were tracked and included events such as witnessed aspiration, oxygen desaturation, esophageal intubation, hypotension, dysrhythmia, and cardiac arrest. Multivariable logistic regression was used to assess the relationship between the primary predictor variable of interest, first pass success, and the outcome variable, the presence of one or more AEs, after controlling for various other potential risk factors and confounders.

Results Over the 4-year study period, there were 1,828 orotracheal intubations. If the intubation was successful on the first attempt, the incidence of one or more AEs was 14.2% (95% confidence interval [CI] = 12.4% to 16.2%). In cases requiring two attempts, the incidence of one or more AEs was 47.2% (95% CI = 41.8% to 52.7%); in cases requiring three attempts, the incidence of one or more AEs was 63.6% (95% CI = 53.7% to 72.6%); and in cases requiring four or more attempts, the incidence of one or more AEs was 70.6% (95% CI = 56.2.3% to 82.5%). Multivariable logistic regression showed that more than one attempt at tracheal intubation was a significant predictor of one or more AEs (adjusted odds ratio [aOR] = 7.52, 95% CI = 5.86 to 9.63).

Conclusions When performing orotracheal intubation in the ED, first pass success is associated with a relatively small incidence of AEs. As the number of attempts increases, the incidence of AEs increases substantially.

Comments

4 Responses to “The importance of first pass success”

  1. gravelord on February 20th, 2013 19:33

    Rather cheap dig at anaesthetists. A bit disappointed as I think it diminishes the message.

  2. Cliff on February 21st, 2013 14:48

    It was meant to be a dig at propofol and those who consider it a mandatory component of RSI even in the critically ill or injured, and a dig at those who consider their expertise to extend beyond their usual workplace and who attempt to take over a resuscitation uninvited at a critical moment. The HEMS doctor is an anaesthetist.
    However if it causes offence or diminishes the message we may have got it wrong so I appreciate you taking the trouble to feed back. The SMACC entry video needed an attempt at humour in it. I will see if we can produce a more educationally sound version without the laddish humour in.
    Best wishes and thanks – I do appreciate your comment.
    Cliff

  3. Eoin on February 25th, 2013 12:38

    Yeah anaesthetist comment seconded – this sort of stuff is pretty tiresome. Most of us realise that things are done differently outside the rarified confines of theatre, and most of us realise propofol can be lethal in certain circumstances. Shame, as your blog is usually pretty good.

    (and most of us aren’t cocks ;) (although occasional cockish tendencies are present, as with every speciality)

  4. Cliff on February 25th, 2013 17:14

    Eoin and gravelord I take your feedback seriously and have removed the video. This site is about saving lives by improving resuscitation practice. I don’t want to detract from the important message in the article with a distraction that could generate a tangential discussion, or rile good clinicians who have taken the trouble to visit the site.
    Cheers
    Cliff