Endotracheal intubation practices, success rates and adverse events in four Dutch emergency departments: a multicentre retrospective study

Abstract

Endotracheal intubation in the emergency department (ED) is a high-risk intervention associated with significant complications. Contemporary European data on emergency airway management remain limited, and no published data are available from the Netherlands. This study aimed to describe endotracheal intubation practices, success rates, and adverse events in four Dutch EDs. We conducted a multicentre retrospective cohort study of patients undergoing endotracheal intubation in four teaching hospital EDs in the Netherlands between January 2019 and December 2023. Patients were identified using procedure registrations, diagnostic codes, billing information and disposition records. Trained abstractors collected standardized data on patient characteristics, indications, provider characteristics, intubation techniques, medications, first-pass success and adverse events. A total of 1250 intubations were included. The most common indication was post–return of spontaneous circulation (ROSC) after cardiac arrest (47%), followed by neurologic pathology (14%), cardiac arrest (12%), respiratory insufficiency (8%), intoxication (8%), and trauma (5%). Emergency medicine and intensive care physicians performed most intubations. Videolaryngoscopy was the primary technique in 89.5% of cases, and etomidate was the most frequently used induction agent (73.5%). The overall first-pass success rate was 93.8% and did not differ by provider specialty or level of training. Adverse events occurred in 181 patients (14.5%), with hypotension (6.5%) and desaturation (4.7%) being most common. Increasing age (OR 1.07 per year, 95% CI 1.04–1.10) and cardiac pathology as indication for intubation (OR 3.50, 95% CI 1.03–11.88) were associated with hypotension. A higher body mass index (OR 1.08 per point, 95% CI 1.03–1.13), younger age (OR 0.98 per year, 95% CI 0.96–1.00, p = 0.022) and multiple intubations attempts (OR 2.9, 95% CI 1.12–7.33) were associated with desaturation. Lower pre-intubation oxygen saturation was associated with peri-intubation cardiac arrest (OR 0.96 per point, 95% CI 0.92–0.99). This study provides the first multicentre description of emergency airway management in Dutch EDs and demonstrates a distinctive emergency intubation population, characterised by a high proportion of post-ROSC intubations. Contemporary practice was characterised by widespread adoption of videolaryngoscopy, frequent use of etomidate, and high first-pass success rates. Peri-intubation hypotension and desaturation remained common and represent important targets for quality improvement. clinicaltrials.gov NCT06374030.