Intubations in an emergency department and intensive care unit at a central hospital

Abstract

Background: The development of the emergency medicine speciality in the emergency department (ED) and the multi-speciality environment of the intensive care unit (ICU) have necessitated airway management skill in specialities other than anaesthesiology. The aim of this study was to describe the intubation process in adult patients within the ED and the general medical and surgical ICU at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Methods: A prospective, contextual, descriptive research design was followed, using a consecutive convenience sampling method. The study population consisted of adult patients requiring intubation within the ED and ICU at CMJAH. Results: The study period was from 2 January to 20 May 2019, and 140 patient intubations were described. The most frequent indication for intubation was a reduced Glasgow coma scale in 56 (40.0%) patients. First attempts at intubation were completed by doctors from: emergency medicine (47.9%), general surgery (17.1%), anaesthesiology (19.3%), internal medicine (9.3%), and obstetrics and gynaecology (6.5%). Junior doctors intubated 133 (95.0%) patients. First-pass attempts occurred in 85.7% of intubations, with no difference in the number of first-pass attempts between ED and ICU (p = 0.340). Ketamine was the favoured induction agent, used in 68 (48.6%) intubations, and rocuronium was the preferred neuromuscular blocker, used in 91 (65%) intubations. Appropriate pharmacological therapy was evidenced in 67 (47.9%) of cases. Adverse events were observed in 22 (15.7%) intubations with haemodynamic instability occurring most frequently, in 16 (11.4%) intubations. Airway-related deaths occurred in 2 (1.4%) intubations. Non-airway related deaths occurred in 5 (3.5%) of intubations. Conclusion: Anaesthetists are no longer involved in the majority of emergency intubations outside of theatre. Junior doctors perform most of the emergency intubations, with similar success rates, peri-intubation adverse events and direct outcomes to that in the literature, despite a high rate of inappropriate drug choice.