Findings do not support early tracheal intubation for in-hospital cardiac arrest in adults

Decreased survival to hospital discharge was found with the initiation of tracheal intubation compared with no intubation in adult patients experiencing in-hospital cardiac arrest when the tracheal intubation was initiated within any given minute during the first 15 minutes of resuscitation, researchers reported.

Lars W. Andersen, MD, MPH, PhD, of the Research Center for Emergency Medicine, Aarhus University Hospital in Denmark, and colleagues conducted an observational cohort study of adult patients who had an in-hospital cardiac arrest to determine whether tracheal intubation during the first 15 minutes of resuscitation is associated with survival to hospital discharge. The findings were presented at the Society of Critical Care Medicine’s Critical Care Congress and published in JAMA.

“Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge,” Andersen and colleagues wrote.

All 108,079 patients included in the study had an in-hospital cardiac arrest at 668 hospitals from 2000 to 2014. The patients were included in the Get With the Guidelines–Resuscitation registry, a U.S.-based multicenter registry of in-hospital cardiac arrest. The median age of the patients was 69 years, and 42% were women (n = 45,073).

The researchers matched patients who were intubated at any given minute of the first 15 minutes of in-hospital cardiac arrest with patients at risk for being intubated within the same minute.

The main outcome was survival to hospital discharge. Other outcomes measured were return of spontaneous circulation and a good functional outcome. A good functional outcome was defined as either a Cerebral Performance Category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability).

Outcomes worse

A total of 71,615 patients were intubated within the first 15 minutes of cardiac arrest. Of these, researchers matched 43,314 to a patient who was not intubated in the same minute.

A total of 22.4% of the patients (n = 24,256) survived to hospital discharge. Among patients who were intubated, survival rates were lower compared with patients who were not intubated (16.3% vs. 19.4%; RR = 0.84; 95% CI, 0.81-0.87).

Also, the number of patients with return of spontaneous circulation was lower in the group that was intubated vs. patients who were not intubated (57.8% vs. 59.3%; RR = 0.97; 95% CI, 0.96-0.99).

Among patients who were intubated, good functional outcome was also lower compared with patients who were not intubated (10.6% vs. 13.6%; RR = 0.78; 95% CI, 0.75-0.81).

Incorporation of evidence

“Andersen and colleagues provide a highly sophisticated analysis of the benefits and harms of endotracheal intubation during CPR. Their approach and findings are instructive both for the provision of [advanced CV life support] and as a window to what lies ahead as regulators, clinicians and researchers envision incorporation of evidence of treatment effectiveness from actual clinical practice settings,” Derek C. Angus, MD, MPH, of the Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, department of critical care medicine, University of Pittsburgh School of Medicine, wrote in a related editorial in JAMA. Angus is also associate editor of JAMA. – by Suzanne Reist

References:

Andersen LW, et al. Hot Topics and Late-Breaking Science II: Hold the Press, Late-Breaking Journal Articles. Presented at: Society of Critical Care Medicine’s Critical Care Congress; Jan. 20-25, 2017; Honolulu.Andersen LW, et al. JAMA. 2017;doi:10.1001/jama.2016.20165.
Angus DC. JAMA. 2017;doi:10.1001/jama.2016.20626.

Disclosure: Andersen and Angus report no relevant financial disclosures. Please see the full study for a list of the other researchers’ relevant financial disclosures.