Non-operating theatre emergency tracheal intubation: a UK multicentre prospective observational study of rapid sequence induction drugs and adverse events.

Authors

Roshan Ramasamy, Alex Hunter, Todd Leckie, Jamie Gibson, Eimear Lusby, Ultan Watson, Matthew Roche, Luke Hodgson, NoTHREAT collaborators

Published in

Anaesthesia. Jul 29, 2026. Epub Jul 29, 2026.

Abstract

Emergency tracheal intubation outside the operating theatre carries increased risk for patients. Guidelines caution against high dose propofol for induction in this context, due to associated haemodynamic instability. This study aimed to describe induction strategies and adverse events for these patients in UK practice.
We conducted a prospective, multicentre cross-sectional service evaluation of adults who required emergency tracheal intubation outside the operating theatre. Data were collected as a convenience sample by anaesthetic and critical care teams using an online form. Primary outcomes were the selection and dose of induction drugs. Secondary outcomes were: vasopressor co-administration; severe hypotension (systolic blood pressure < 80 mmHg); severe hypoxia (peripheral oxygen saturation < 80%); and cardiac arrest.
Twenty-three NHS hospitals reported 250 emergency tracheal intubations. Not including 17 (7%) performed during cardiac arrest, there were 233 rapid sequence inductions. Propofol was used in 147 (63%); fentanyl in 172 (74%); ketamine in 53 (23%); and midazolam in 51 (22%). Propofol with fentanyl was the most common combination (97/233, 42%), at median (IQR [range]) doses of 1.4 (0.8-2.0 [0.04-3.3]) mg.kg^-1 and 2.0 (1.3-2.9 [0.5-6.0]) μg.kg^-1, respectively. Severe hypotension affected 24/219 (11%) patients with recorded post-induction blood pressures. Severe hypoxia affected 14/221 (6%) patients with recorded post-induction oxygen saturations. Post-induction cardiac arrest occurred in 6/233 (3%) patients. For patients who did not receive pre-emptive vasopressors at induction, 40/105 (38%) subsequently required vasopressor administration.
Patients who required tracheal intubation outside operating theatres experienced high rates of post-induction hypotension. Propofol was the most used induction drug, often at doses typical for elective anaesthesia. Pre-emptive vasopressor use was inconsistent. These practices deviate from existing guidelines and represent a modifiable risk factor for adverse events. We recommend standardised protocols for tracheal intubation outside operating theatres, including guidance on induction drug selection, dose and pre-emptive vasopressor use.

PMID:
42522669
Bibliographic data and abstract were imported from PubMed on 29 Jul 2026.

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