Morbidity Related to Emergency Endotracheal Intubation—A Substudy of the KETAmine SEDation Trial

This retrospective study from France looked at prospectively collected data from the KETAmine SEDation (KETASED) trial to evaluate the association between intubation difficulty and the occurrence of immediate complications and 28-day mortality. In the KETASED trial, patients over the age of 18 years requiring sedation for emergency tracheal intubation in a mobile intensive care unit (ICU) or ambulance were randomized to receive either ketamine or etomidate in combination with a paralytic agent (succinylcholine). Patients were excluded if they were in cardiac arrest, had contraindications to succinylcholine, ketamine, or etomidate, or were known to be pregnant. The intubation technique was standardized between mobile ICUs. The emergency physicians performing the procedure recorded complications recognized within 5 min of intubation. Intubation difficulty was assessed using the Intubation Difficulty Score (IDS), which included a number of attempts excluding the first, number of operators, number of additional techniques used, Cormack grade, intensity of lifting force required, need for external laryngeal pressure, and vocal cord position. The physician who performed the procedure recorded the IDS. IDS > 5 was considered difficult. A total of 650 patients were included: 539 medical patients, 111 trauma patients. Of these, 473 (73%) were intubated for neurologic reasons, 86 (13%) for acute respiratory distress, 73 (11%) for shock, and 18 (3%) for other reasons. The median IDS was 1. In 211 patients (32%), an IDS of 0 (easy intubation) was recorded. An IDS > 5 (difficult intubation) was recorded in 73 (11%) patients. In 192 patients (30%), 248 complications occurred, the most common being hypotension and oxygen desaturation. Patients with any complication related to intubation had a significantly higher median IDS compared to those without complications. Patients with complications were also found to be significantly older, had higher body mass index (BMI), a medical disorder (rather than trauma), and usually were intubated for respiratory distress. The authors of this study found a linear relationship between IDS and complication rate. An analysis of 28-day mortality showed that difficult intubation (IDS > 5) was an independent predictor of death after adjustment for age and BMI. The authors concluded that early complications of emergency intubation were associated with difficult intubation as well as intubating for respiratory reasons. They also concluded that difficult intubation was associated with early death.