Introduction: Intubation is a high risk procedure which requires extensive preparation and planning. Many factors can increase the risk of complication, such as urgency, comorbidities, patient acuity, and intubation setting. Outside of the operating room, most hospital intubations occur in the ICU and ED. Intubations in these settings are often performed without the luxury of extensive preparation and optimization of patient hemodynamics prior to the procedure and therefore are at high risk for peri-intubation complications. In critically ill patients, about 30-45% will experience a complication during the peri-intubation period. Common complications such as hypoxemia and cardiovascular collapse are associated with increased in-hospital mortality. In this secondary analysis of the DEVICE and PREOXI trials we sought to compare intubation outcomes in these settings. The DEVICE and PREOXI trials examined patients intubated in emergency departments and intensive care units around the country. We performed a secondary propensity matched analysis of these trials with the hypothesis that mortality would be higher in patients who were intubated in the emergency department setting. Methods: We performed a retrospective analysis of data from two multicenter, randomized clinical trials, DEVICE and PREOXI, including 2440 patients from 9 EDs and 24 ICUs around the country. Adult intubated in the ED or ICU were eligible for randomization and excluded if they were pregnant or incarcerated. Primary outcomes included one hour and 28 day mortality. Admission diagnoses, patient comorbidities, APACHE II scores, age, and BMI were also documented and were used for our propensity matched cohort analysis and compared with a Chi Square test of independence. Results: 1214 ICU and 1226 emergency department patients were included in our secondary analysis with 894 randomized in each setting. One hour mortality was significantly higher in the ED with 40 Patients (3.3%) dying vs 7 (.6%) in the ICU (p <.001) whereas morality at 28 days was higher in the patients intubated in the ICU (482/39.7%) vs the ED (238/19.8%) (p<.001). Conclusions: In this secondary analysis of the PREOXI and DEVICE trials show increased one hour mortality associated with intubation in the ED and increased 28 day mortality associated with intubation in the ICU.
Jackson et al. (Sun,) studied this question.