title: Reintubation in critically ill patients: procedural complications and implications for care.
abstract: BACKGROUND
  In critically ill patients, re-intubation is common and may be a high-risk procedure. Anticipating a difficult airway and identifying high-risk patients can allow time for life-saving preparation. Unfortunately, prospective studies have not compared the difficulty or complication rates associated with reintubation in this population.
  
  
  METHODS
  We performed a secondary analysis of a prospective registry of in-hospital emergency airway management, focusing on patients that underwent multiple out-of-operating room intubations during a single hospitalization. Our main outcomes of interest were technical difficulty of intubation (number of attempts, need for adjuncts to direct laryngoscopy, best Cormack-Lehane grade and training level of final intubator) and the frequency of procedural complications (aspiration, arrhythmia, airway trauma, new hypotension, new hypoxia, esophageal intubation and cardiac arrest). We compared the cohort of reintubated patients to a matched cohort of singly intubated patients and compared each repeatedly intubated patient's first and last intubation.
  
  
  RESULTS
  Our registry included 1053 patients, of which 151 patients (14%) were repeatedly intubated (median two per patient). Complications were significantly more common during last intubation compared to first (13% versus 5%, P = 0.02). The most common complications were hypotension (41%) and hypoxia (35%). These occurred despite no difference in any measure of technical difficultly across intubations.
  
  
  CONCLUSIONS
  In this cohort of reintubated patients, clinically important procedural complications were significantly more common on last intubation compared to first.
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15261, USA. elmerjp@upmc.edu.|Department of Emergency Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, Iroquois Building Suite 400A, Pittsburgh, PA, 15213, USA. elmerjp@upmc.edu.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Elmer
authors.affiliation: Department of Emergency Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, Iroquois Building Suite 400A, Pittsburgh, PA, 15213, USA. leesean78@gmail.com.
authors.forename: Sean
authors.initials: S
authors.lastname: Lee
authors.affiliation: Department of Emergency Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, Iroquois Building Suite 400A, Pittsburgh, PA, 15213, USA. rittjc@upmc.edu.
authors.forename: Jon C
authors.initials: JC
authors.lastname: Rittenberger
authors.affiliation: Department of Pulmonary & Critical Care Medicine, Lahey Medical Center & Hospital, 41 Mall Road, Burlington, 01805, MA, USA. James.M.Dargin@Lahey.org.
authors.forename: James
authors.initials: J
authors.lastname: Dargin
authors.affiliation: Clinical and Translational Science Institute, University of Pittsburgh, Forbes Tower Suite 7057, Pittsburgh, PA, 15206, USA. dgw14@pitt.edu.
authors.forename: Daniel
authors.initials: D
authors.lastname: Winger
authors.affiliation: Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Pittsburgh, PA, 15261, USA. emlell@ccm.upmc.edu.|Department of Emergency Medicine, University of Pittsburgh School of Medicine, 3600 Forbes Avenue, Iroquois Building Suite 400A, Pittsburgh, PA, 15213, USA. emlell@ccm.upmc.edu.
authors.forename: Lillian
authors.initials: L
authors.lastname: Emlet
mesh_terms: D015331:Cohort Studies; D016638:Critical Illness; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects* / Q000379:methods; D007828:Laryngoscopy / Q000009:adverse effects / Q000379:methods; D008297:Male; D008875:Middle Aged; D019233:Retreatment / Q000009:adverse effects