In patients with a predicted difficult airway: weekend versus weekday presentation increases the risk of tracheal intubation-complications

Myron Yaster MD, James M Peyton MBChB, MRCP, FRCA, Mary Lyn Stein, MD

It’s an age-old and common belief that surgery performed on nights or weekends, will have significantly increased risks of complications, readmissions, and mortality compared with those treated in normal business hours. See previous PAAD April 01, 2025.

In today’s PAAD. Crockett et al.[1] wondered if patients with a difficult airway would fare worse if their care were on weekends compared to weekdays?

Original article

Crockett CJ, Szolnoki J, Khan S, Lee AC, Kaizer A, Olomu P, Brooks Peterson M; Pediatric Difficult Intubation Collaborative. Paediatric difficult intubations and the impact of timing of weekend versus weekday cases: an analysis of the Pediatric Difficult Intubation registry. Br J Anaesth. 2025 Aug 18:S0007-0912(25)00447-7. doi: 10.1016/j.bja.2025.07.033. Epub ahead of print. PMID: 40829974.

“The primary objective of this retrospective study was to compare the total complication rates associated with paediatric difficult airway management between weekends (Satday/Sunday) and weekdays (Monday through Friday). Secondary objectives included analysing hypoxaemia incidence (hypoxaemia is defined as oxygen saturation less than 90% for 1 min or longer), non-hypoxaemia complications, and first-attempt success rates during paediatric difficult airway management on weekdays vs weekends. Non-hypoxaemia complications included airway trauma, pharyngeal bleeding, epistaxis, vomiting, aspiration, oesophageal intubation, bronchospasm, laryngospasm, arrhythmia, cardiac arrest, death, pneumothorax, and other. We hypothesised that the rates of all complications and secondary complication types would be higher on weekends compared with weekdays.”[1]

In this retrospective study of the pediatric difficult airway registry data, the primary objective was to compare total complication rates when children with difficult airways were cared for on the weekends versus on weekdays. This hypothesis was based on the premise that there might be fewer resources (human or otherwise) available for weekend cases and thus complications rates may be higher on the weekends. The authors also compared the incidence of hypoxia (pulse oximeter reading <90% for a minute or more), complications other than hypoxia, and first attempt intubation success rates. The study included 8031 cases of difficult intubations from the Pediatric Difficult Intubation Registry (June 8, 2012 to May 9, 2023). The vast majority 7746 (96.5%) were performed on a weekday, while only 285 (3.5%) were performed on the weekend.

What did they find? “The odds of any complication were more than two times higher on the weekends compared with weekdays (odds ratio 2.13, 95% confidence interval 1.49—3.07, P<0.0001).”

And the authors conclude: “This study supports pediatric anesthetists’ clinical decision-making to postpone nonurgent pediatric procedures in children with a history of a difficult airway from weekend to weekday to decrease risk of airway management complications and improve patient safety and quality of care.”[1]

There are some very important caveats and limitations that the authors identified in this article. More patients had higher ASA PS levels (IV and V) and were intubated emergently in the off hours group. Further, “weekend difficult intubations were characterised by significantly more cervical spine mobility issues and facial trauma, while weekdays saw significantly more cases of micrognathia, microtia, facial asymmetry, and cleft palates (P < 0.005 for each}”[1] We could also say that weekend difficult airways tended to occur in the setting of acquired or traumatic anatomic difficulties while the weekdays were characterized more by congenital or developmental anatomic difficulties. Interestingly despite these differences, neonates were overrepresented in weekend cases (16.8% weekend vs 10% weekday) and school aged children and teenagers were underrepresented in weekend cases (42.8% weekend vs 51.8% weekday).

Hypoxia was twice as likely to occur in weekend cases although the association did not achieve statistical significance once the authors adjusted for potential confounders including age, ASA physical status, emergency cases, prematurity, and diagnosed syndrome (OR1.29, 95% CI 0.77—2.16, p=0.336 ), indicating that other factors likely contributed more to the occurrence of hypoxia than the timing of the case. In both weekend and weekday cases, hypoxia was primarily attributed to prolonged intubations attempts and the patient’s underlying medical condition. Interestingly, while airway activation was a cause of hypoxia in 17.5% of weekday cases, it was reported in a weekend case. I (MLS) have to wonder if this is due to more use of muscle relaxants[2] on weekends – although this data isn’t reported in the manuscript as depth of anesthesia and use of controlled ventilation have been shown to be important in children with difficult airways.

Regardless of when intubations occurred and who was performing them (trainees, staff etc), videolaryngoscopy was the most successful method of intubation – corroborating nearly a decade of evidence the direct laryngoscopy is not a great choice for children with difficult airways.[3-5]

Why is this study so important? “This study provides evidence that paediatric difficult airway management, both emergent and non-emergent, carries a higher risk of complications on weekends (Saturday/Sunday) compared with weekdays (Monday through Friday). These findings raise the consideration that nonemergent surgical cases in patients with known difficult airways should safely be postponed until weekday hours to decrease the risk of complications.”

This appears to be a pretty clear and intuitive recommendation. But as Crockett et al. point out: “in today’s healthcare climate marked by operational, financial, and scheduling pressures, decisions that prioritise safety over convenience require clear, data-driven, and evidence-based justification. Our findings offer this support and are intended to empower clinicians advocating for safer care practices in vulnerable paediatric populations.”[1]

JP: I’m glad the authors persisted with this project, as I know it was a challenging one to bring to fruition, having originally been proposed many years ago. I think it represents an innovative use of the data within the PeDIR and shows the value, once again, of such large-scale collaborations. It is also worth noting that other studies have shown similar findings. Recently, the 7^th National Audit Project (NAP 7) reported on serious complications related to non-obstetric surgery in the UK.[6] A subanalysis of airway-related complications was also published.[7] These studies found that airway and respiratory complications accounted for approximately 1 in 3 potentially serious complications during anesthesia, and 1 in 7 perioperative cardiac arrests. Importantly, when discussing this latest study from the PeDI collaborative, these UK-based studies also noted that airway-related cardiac arrest occurred disproportionately out-of-hours, as well as neonates and infants being ‘overrepresented’ in the study, showing that this group in particular is at higher risk for serious complications during out-of-hours surgery. These are all-comers, and not specifically patients who were difficult to intubate, but they illustrate how our patient population can cause more problems than others.

As pediatric anesthesiologists, our mission is to safely shepherd children with increasingly complex medical needs through diagnostic and therapeutic procedures as safely and comfortably as possible. This study highlights how important the timing of these procedures can be for patient safety. We now have the data to support what many of us have been saying all along – a child with a known difficult airway and a non-urgent procedure should be delayed to regular working hours – and we cannot allow service, patient relations, or economic pressures to blur this line. But just as importantly, this study has lessons to offer for cases that cannot be delayed, and those in which the difficulty is unanticipated. The body of evidence from the PeDI collaborative and others is overwhelming now; direct laryngoscopy is a poor choice for children with difficult airways, and persisting with failing techniques leads to more and more serious complications for our patients. So to us, the logical solution is to start with the technique most likely to be successful – no more DLs just to see if we don’t believe it’s likely to succeed. And if we try with DL and fail, we’ve got to move on. But for us individual clinicians to be able to make these choices, advanced airway equipment must be at hand when we need it, which means organizations must invest in this infrastructure and provide appropriate equipment that is readily available and regularly used.

We all know airway management is easy, until it isn’t. This study once again demonstrates that we shouldn’t be lulled into a false sense of security. Concerns about airway management should play a crucial role in our risk assessment when evaluating children for surgery outside regular working hours. It is legitimate to raise concerns about patient safety when the benefit of operating outside of regular working hours is not clear.

What do you think? Send your thoughts and comments to Myron (myasterster@gmail.com) and he will post in a Friday reader response.

References

1. Crockett CJ, Szolnoki J, Khan S, Lee AC, Kaizer A, Olomu P, Brooks Peterson M: Paediatric difficult intubations and the impact of timing of weekend versus weekday cases: an analysis of the Pediatric Difficult Intubation registry. British journal of anaesthesia 2025.

2. Garcia-Marcinkiewicz AG, Adams HD, Gurnaney H, Patel V, Jagannathan N, Burjek N, Mensinger JL, Zhang B, Peeples KN, Kovatsis PG et al: A Retrospective Analysis of Neuromuscular Blocking Drug Use and Ventilation Technique on Complications in the Pediatric Difficult Intubation Registry Using Propensity Score Matching. Anesthesia and analgesia 2020, 131(2):469–479.

3. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P et al: Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016, 4(1):37–48.

4. Peyton J, Park R, Staffa SJ, Sabato S, Templeton TW, Stein ML, Garcia-Marcinkiewicz AG, Kiss E, Fiadjoe JE, von Ungern-Sternberg B et al: A comparison of videolaryngoscopy using standard blades or non-standard blades in children in the Paediatric Difficult Intubation Registry. British journal of anaesthesia 2021, 126(1):331–339.

5. Stein ML, Nagle JH, Templeton TW, Staffa SJ, Flynn SG, Bordini M, Nykiel-Bailey S, Garcia-Marcinkiewicz AG, Padiyath F, Matuszczak M et al: Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry. Anaesthesia 2025, 80(6):625–635.

6. Kane AD, Cook TM, Armstrong RA, Kursumovic E, Davies MT, Agarwal S, Nolan JP, Smith JH, Moppett IK, Oglesby FC et al: The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey. Anaesthesia 2024, 79(1):43–53.

7. Cook TM, Oglesby F, Kane AD, Armstrong RA, Kursumovic E, Soar J: Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists. Anaesthesia 2024, 79(4):368–379.