High-Risk, Low-Frequency: Pediatric Intubation Complications Across Care Settings (A Scoping Review)

INTRODUCTION:
Pediatric endotracheal intubation is a high-risk, technically challenging procedure performed in PICUs, EDs, and by Emergency Medicine Services (EMS). Complications such as hypoxia, bradycardia, and esophageal intubation contribute to significant morbidity and mortality, particularly in younger children. First-pass success (FPS) is a key quality metric, as multiple attempts increase adverse events. Provider experience, training, and system infrastructure vary widely, as do reported complications across care settings, highlighting variability that directly impacts patient safety and underscoring the need to examine complication patterns across these environments.

MAIN BODY:
This scoping review was conducted according to the Population, Concept, Context (PCC) framework. Eligible studies included pediatric patients (0-18 years) undergoing endotracheal intubation, with complications such as hypoxia, bradycardia, esophageal intubation, cardiac arrest, and multiple attempts defined as primary concepts of interest. The context included EMS, Emergency Departments (EDs) (both general and pediatric), and Pediatric Intensive Care (PICU) settings. A literature search using PubMed and ResearchRabbit identified 32 peer-reviewed studies meeting inclusion criteria. Extracted data included provider type, patient age, number of attempts, use of rapid sequence intubation (RSI), intubation method (video versus direct laryngoscopy), data source (e.g., NEAR4KIDS, NEMSIS), reported complications, and FPS. PICU studies demonstrated the most complete and structured complication tracking, particularly those using NEAR4KIDS registry data. Commonly reported complications included desaturation (16%), esophageal intubation (11%), and aspiration (9%), with tracheal intubation-associated event (TIAE) rates ranging from 17-30%. However, NEAR4KIDS does not report FPS or the total number of attempts; it only captures attempts greater than three. This limits analysis of how provider experience or procedural familiarity may influence outcomes across institutions and training levels. This is an especially important consideration in a low-frequency, high-risk procedure like pediatric airway management. ED studies showed greater variability in reporting, influenced by whether the institution was pediatric-specific or general. Cardiac arrest (26%), aspiration (10%), and hypoxia (10%) were the most frequently mentioned complications. Pediatric EDs more often reported physiologic complications and intubation technique, while general EDs often limited documentation to procedural outcomes like FPS or total success. EMS studies had the least comprehensive complication reporting, with many focusing solely on intubation success or cardiac arrest outcomes. Cardiac arrest was the most frequently reported complication (35%), followed by non-specific mentions of "complications" or vomiting. Physiologic complications such as hypoxia and bradycardia were rarely documented, and reporting standards varied significantly across studies. Across settings, multiple attempts were present or inferable in 68% of studies and consistently correlated with increased adverse events. The use of RSI and video laryngoscopy was underreported in both EMS and general ED settings, limiting analysis of technique-related outcomes.

CONCLUSION:
Pediatric intubation complications occur across care environments and are commonly underreported. The lack of standardized reporting, particularly in EMS systems, hinders benchmarking and quality improvement. Complication rates appear highest in EMS and general EDs, both in frequency and in reporting gaps. Future efforts should focus on improving the consistency and quality of intubation and complication reporting to support benchmarking, targeted training, and safer pediatric airway management.