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27-01-2017 | Emergency medicine | News | Article

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Early tracheal intubation after cardiac arrest contested

medwireNews: Study results published in JAMA suggest that tracheal intubation performed within the first 15 minutes of in-hospital cardiac arrest is associated with decreased survival compared with no intubation during this timeframe.

“These findings do not support early tracheal intubation for adult in-hospital cardiac arrest,” say Lars Andersen (Aarhus University Hospital, Denmark) and fellow researchers.

Using data from the US Get With The Guidelines–Resuscitation multicenter registry, the team found that 16.3% of 43,314 patients who were intubated within 15 minutes survived to hospital discharge, compared with 19.4% of 43,314 matched patients who underwent resuscitation but were not intubated in the same minute, a significant difference.

These results translate into a 3% absolute reduction and 16% relative reduction in survival to hospital discharge with intubation versus no intubation within 15 minutes, note the authors.

Furthermore, the proportion of patients with return of spontaneous circulation was significantly lower among intubated compared with non-intubated patients, at 57.8% versus 59.3%, as was the rate of good functional outcome, at 10.6% versus 13.6%.

“So, should clinicians conclude that early intubation is harmful or, at least, ineffective and unnecessary?” asks Derek Angus (University of Pittsburgh School of Medicine, Pennsylvania, USA) in an accompanying editorial.

He says that intubation “should not directly cause injury or death,” especially when performed by skilled clinicians, but “distraction from effective chest compressions while intubation is performed could certainly be harmful.”

“The lack of demonstrable benefit of intubation does challenge conventional wisdom, perhaps to the degree that would generate adequate equipoise for a future [randomized controlled trial],” he adds.

The study authors caution that the data registry used in the study did not contain information on unsuccessful intubation attempts, and potential confounders such as the cause of cardiac arrest and the experience of healthcare professionals could not be accounted for.

Angus agrees, commenting that “even data analyses of this size, detail, and sophistication are insufficient to exclude residual confounding.”

He also notes that while “control” patients in the study were not intubated during the same minute as their matched “cases,” they may have been intubated in subsequent minutes, meaning that “this is a comparison of those intubated vs those who are either never intubated or not intubated yet.”

However, he believes that “[t]he data set is large, generalizable, and richly detailed with information to permit sophisticated risk adjustment.”

By Claire Barnard

medwireNews is an independent medical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2017

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