Endotracheal intubation in the critically ill: complication rate and use of intubation aids

Introduction

Intubation in the ICU is associated with a high complication rate. No data exist about how frequently intubation aids are used in the ICU. In our ICU we have the availability of different intubation aids, and perform an annual training course on difficult intubation strategy. We wanted to evaluate the incidence of difficult intubation, together with the complication rate and the use of intubation aids in our ICU.

Methods

We performed a prospective cohort study in a 56-bed academic tertiary care hospital of all patients requiring intubation during their ICU stay during a 5-month observation period in 2008. Standardized data forms were used to collect detailed information on the intubating physicians, supervisors, techniques, medications and complications.

Results

We enrolled 120 patients requiring immediate intubation in 37.5%, semi-urgent (<30 minutes) intubation in 50.8%, and semi-elective intubation in 11.7%. All intubations were successful. Difficult intubation was anticipated in 17.5% of all cases, although only 28% of these effectively proved to be difficult. Immediate intubation was possible in 74.2% of all cases, and difficult intubation (at least three attempts) occurred in 6.6%. Furthermore, 4.2% of intubations required 10 minutes or more. Nonexperts experienced more complications, and performed successful intubation in only 37.7%. One-third of all intubations were supervised by an intensive care physician, although this was not associated with a decrease of complication rate (65% vs 57.5%). Techniques most commonly used for difficult intubation management were change in intubator (48.4%), change in patient position (29%), BURP maneuver (19.3%) and use of a Gum elastic bougie (19.3%). Overall risk of complications occurring was 76.6%. Hypoxia was most common (40%), followed by hypotension (31.6%), heart rhythm disorders (4.1%) and oesophageal intubation (3.3%). Neuromuscular blockade was used in all but one patient. Hypnomidate was used in 31.6% of intubations, preferentially in patients with shock. The rate of complications or mortality did not significantly differ according to the hypnotic drug used.

Conclusions

Intubation in the ICU is frequently associated with complications, most commonly hypoxia and hypotension. The use of the Gum elastic bougie is required in 19.3% of cases, and results in achieving a 100% successful intubation rate.