Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study
Ian Ward Abdalla Maia, Bruno Adler Maccagnan Pinheiro Besen, Lucas Oliveira J. e Silva, Rafael von Hellmann, Ludhmila Abrahão Hajjar, Benjamin J. Sandefur, Daniel Pedrollo, Caio Goncalves Nogueira, Natalia Mansur P. Figueiredo, Carlos Henrique Miranda, Danilo Martins, Thiago Dias Baumgratz, Bruno Bergesch, Diogo Costa, Osmar Colleoni, Juliana Zanettini, Ana Paula Freitas, Nicole Pinheiro Moreira, Patrícia Lopes Gaspar, Renato Tambelli, Maria Cristina Costa, Samara Silveira, Wilsterman Correia, Rafael Garcia de Maria, Ubirajara A. Vinholes Filho, Andre P. Weber, Vinicius da Silva Castro, Carlos Fernando Drumond Dornelles, Barbara S. Tabach, Hélio Penna Guimarães, Gabriela Stanzani, Thiago F. Gava, Aidan F. Mullan, Heraldo Possolo de Souza, Otávio T. Ranzani, Fernanda Bellolio, Júlio César Garcia de Alencar, the BARCO group, Victor Paro da Cunha, Júlio Flávio Meirelles Marchini, Patricia Albuquerque de Moura, Fernanda Greco, Y. Di Filippo, Rubens Yoshinori Kai, Guilherme Torres Abi Ramia Chimelli, J. Insausti Valdivia, Edson Luiz Fávero, Felipe Antonio Rischini, Vitor Amorim de Andrade Câmara, Henrique Bertotto, VICTOR HUDSON DE LACERDA BORGES, Juliano Juliano Rathke, Renato Bessa Melo, Ariadine Augusta Maiante, Sarah Maciel Silva, Clarisse Moreira Ribeiro de Oliveira, Andressa Pi Rocha Reis, Thamyres de Carvalho Rufato, Gabriella Melo Fontes Silva Dias, Victória Sartor Poloni, Kauê Lima, Hilana K Zenly, José Carlos Motta-Junior, Gabriel Fernandes de Miranda, Alexandre Abreu de Freitas, Leonardo Gasperini, Thais Raimondi Sudbrack, Ana Paula Ribeiro, Guilherme Henrique Ávila do Carmo, Andrea de Vargas Tomelero, Augusto Lengler Konrath, Vitor Cremonese Zanella, N Fuhr, Davi Amaral Cesário Rosa, I. Lima, Luiz Fernando Varela, Isabella Baldino, Andre Zimerman, Julia M. Dorn de Carvalho, Molly M. Jeffery
Abstract
BACKGROUND: Emergency tracheal intubation in critically ill patients carries a high risk of complications, and practices vary substantially across different settings. Identifying risk factors and understanding how peri-intubation adverse events affect patient outcomes may guide standardization of care and improve survival. METHODS: This prospective cohort study involved 18 emergency departments in Brazil (March 2022-April 2024). We included adults (≥ 18 years) undergoing emergency intubation and excluded patients intubated electively or for cardiac arrest. We defined major peri-intubation adverse events as severe hypoxemia, new hemodynamic instability, or cardiac arrest occurring within 30 min of initiating intubation. The primary outcome was 28-day mortality. Multivariable regression analyses assessed associations between adverse events and mortality, controlling for potential confounders. RESULTS: Among 2846 patients, major adverse events occurred in 919 (32.3%) intubations, most frequently new hemodynamic instability (20.0%), followed by severe hypoxemia (12.5%) and cardiac arrest (3.5%). The overall 28-day mortality was 45.1%. Patients experiencing any major adverse event had a significantly higher 28-day mortality (57.6 vs 39.2%; aHR 1.43, 95% CI 1.26-1.62; p < 0.001). Sensitivity analyses confirmed these findings. Successful first-attempt intubation was associated with a reduced likelihood of major adverse events (aOR 0.52; 95% CI 0.41-0.65; p < 0.001). CONCLUSION: One in three patients undergoing emergency intubation experienced a major peri-intubation adverse event, which was associated with higher 28-day mortality. These results underscore the importance of optimizing intubation strategies to reduce complications and potentially improve patient outcomes in critically ill patients.