Complications in neonates with difficult tracheal intubation: an analysis of the Pediatric Difficult Intubation Registry

INTRODUCTION: Difficult tracheal intubation is associated with serious complications, including hypoxia, bradycardia and cardiac arrest. Neonates have increased physiologic vulnerability compared with older children, yet detailed data on management strategies and outcomes in neonates with difficult tracheal intubation remain limited. We hypothesised that clinicians have lower first-attempt tracheal intubation success and higher complication rates for neonates compared with older children with difficult tracheal intubation. METHODS: We analysed the Pediatric Difficult Intubation Registry to determine tracheal intubation first attempt success and incidence of complications. We used logistic regression to identify variables associated with complications in neonates. RESULTS: During the study period, 6283 paediatric difficult tracheal intubations were recorded, including 420 neonates. First attempt success was lower for neonates (139/420, 33.1%) than older children (2394/4683, 51.1%). Complications occurred more frequently in neonates (123/420, 29.3%) than older children (637/4683, 13.6%). Hypoxia occurred in 92/420 (21.9%) neonates and 269/4683 (5.7%) older children. Severe complications were more frequent in neonates vs. older children (12/420, 2.9% vs. 30/4683, 0.6%, respectively), with cardiac arrests occurring in 4/420 (1.0%) neonates and 11/4683 (0.2%) older children. Difficult mask ventilation occurred more frequently in neonates (60/420, 14.3%) than older children (353/4681, 7.5%). In neonates, increased number of tracheal intubation attempts (aOR 1.61 per attempt, 95%CI 1.30-2.00, p < 0.001) and difficult facemask ventilation (aOR 3.17, 95%CI 1.38-7.30, p = 0.007) were associated with complications. Anticipated difficulty with airway management had a protective effect (aOR 0.37, 95%CI 0.16-0.88, p = 0.025). DISCUSSION: Neonates with difficult tracheal intubation experience a substantially higher rate of complications than older children. Early recognition of risk is critical in order to enable careful planning to minimise tracheal intubation attempts in this vulnerable population.