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Originally published by 2 Minute Medicine® (view original article). Reused on AccessPediatrics with permission.

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1. Advance practitioners and neonatal fellows had the highest rates of neonatal tracheal intubation (TI) attempts in the neonatal intensive care unit (NICU) and delivery room (DR), while residents had fewer attempts. There was a significant association between the degree of training held by the intubator and the success of the attempt.

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2. There was significant variation between centers with regards to tracheal intubation adverse events (TIAEs). One of the most common TIAEs was esophageal intubation. Paralytic premedication and video laryngoscopy were associated with lower odds of TIAEs.

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Evidence Rating Level: 2 (Good)

Study Rundown:

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Neonatal TI is a high-risk procedure that is commonly performed for a variety of conditions in the NICU and DR. The purpose of this international, multicenter, and retrospective study was to describe the practices and adverse events associated with neonatal TI in the NICU and DR using data from the National Emergency Airway Registry for Neonates (NEAR4NEOS). In the NICU, the most common first attempts to intubate were made by advanced practitioners (i.e. Nurse Practitioners, Physician Assistants, Hospitalists), followed by fellows and residents. In contrast, first attempts to intubate in the DR were most commonly made by fellows, and then attendings. The rate of first attempts in the DR by pediatric residents was 15% and 2%, respectively. The most common nonsevere TIAE was esophageal intubation and the most common severe TIAE was esophageal intubation with delayed recognition. There was significant variation between TIAE rates between centers. Factors that significantly increased the odds of TIAEs included intubation for hemodynamic instability and increased number of attempts, while factors that decreased the odds included use of a video laryngoscope and paralytic premedication. Limitations of this study include the use of self-reported data and no data from community-based NICUs. For training programs, the low rates of resident attempts at intubations may suggest the need for preferential training in TI for those who will need the skill in future practice. Data from this study also suggests that paralytic premedication and video laryngoscopy may result in reduced TIAEs.

In-Depth [retrospective cohort]:

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2607 TIs were captured across 10 academic centers in North America, Europe, and Asia between October 2013 and March 2017. More TIs occurred in the NICU (N = 2009, 77%) compared to the DR (N = 598, 23%). In the NICU, first attempts were most commonly made by advanced practitioners (38%), fellows (30%), and residents (15%). In the DR, first attempts were most commonly made by fellows (49%), advanced practitioners (36%), attendings (5%), and residents (2%). There was a significant association between the level of training held by the intubator and success on first attempt (P <.001), with attending neonatologists having the most success, followed by neonatology fellows, and pediatric residents. The most common nonsevere TIAEs in both settings were esophageal intubations (N = 260, 21%), dysrhythmias (N = 94, 7%), and mainstem bronchial intubations (N = 39, 3%). The most common severe TIAEs were esophageal intubation with delayed recognition (N=27, 2%), cardiac compressions (N = 24, 1%), and laryngospasm (N = 15, 1%). There was significant variation in TIAE rates between centers (range 9-50%, P <.001) and the rates of severe oxygen desaturation (range 29-69%, P <.001). Factors that significantly increased the odds of TIAEs included TI indicated for unstable hemodynamics (aOR = 3.85, 95%CI = 1.59-9.35) and increased number of intubation attempts (aOR = 1.87, 95%c CI = 1.63-2.14). Factors that significantly lowered the odds of TIAEs use of a video laryngoscope (aOR = 0.46, 95% CI = 0.28-0.73) and paralytic premedication (aOR = 0.38, 95% CI = 0.25-0.57).

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