Comparative Analysis of Tracheal Intubation-Associated Cardiac Arrest in 2015-2023: A Report From the National Emergency Airway Registry for Children Multicenter Registry

Summary

This retrospective cohort used prospectively collected NEAR4KIDS registry data from 27,773 initial tracheal intubations in pediatric and pediatric cardiac ICUs from 2015 through 2023. Tracheal intubation-associated cardiac arrest occurred in 331 intubations (1.2%). Pre-intubation oxygenation failure and shock were associated with higher arrest odds, and each additional intubation attempt was associated with progressively higher risk; video laryngoscopy, neuromuscular blockade, ketamine, and propofol were associated with lower odds in adjusted analyses.

Why it matters

The modifiable signal is procedural and physiologic: optimize oxygenation and hemodynamics before pediatric intubation and prioritize first-attempt success. The medication and device associations are hypothesis-generating and should not be converted into causal ED protocol changes from this registry study alone.

Main findings

• Tracheal intubation-associated cardiac arrest occurred in 331 of 27,773 intubations (1.2%).
• Pre-intubation oxygenation failure and shock were associated with higher odds of intubation-associated cardiac arrest.
• Each additional tracheal intubation attempt was associated with higher arrest odds.
• Ketamine, propofol, neuromuscular blockade, and video laryngoscopy were associated with lower adjusted odds; these observational associations do not establish causality.

Limitations

This was an observational PICU/PCICU registry study rather than an ED randomized trial, so residual confounding and setting-specific practice are important. Associations involving induction drugs, neuromuscular blockade, and video laryngoscopy do not prove those choices prevent arrest.