Pre-Existing Right Ventricular Dysfunction as an Independent Risk Factor for Post Intubation Cardiac Arrest and Hemodynamic Instability in Critically Ill Patients: A Retrospective Observational Study

Abstract

Background Post intubation cardiac arrest and hemodynamic instability are serious adverse events encountered in critically ill patients. The association of pre-existing right ventricular (RV) dysfunction with post intubation cardiac arrest and hemodynamic instability in critically ill patients is unknown. Methods This is a retrospective matched cohort study of adult critically ill patients who underwent intubation from July 2016 to December 2019. The study was conducted at a quaternary medical center in Houston, Texas. A total of 340 critically ill patients who underwent intubation in the intensive care units, wards, and the emergency room were included. The study cohort was categorized into 4 groups based on the pre-existing RV function: normal function, mild dysfunction, moderate dysfunction, and severe dysfunction. Cardiac arrest and/or hemodynamic instability within one hour post intubation were the primary study outcomes. Secondary outcomes included in hospital and 60-day mortality. Results Study patients were of mean age of 61.95 ± 14.28 years, including 132 (39%) females and 208 (61%) males. The primary outcomes were significantly worse in mild, moderate, and severe RV dysfunction groups compared to the normal RV function group (34.12%-P = 0.014, 47.06%-P < 0.001, 51.67%-P < 0.001, vs. 17.56%). In a multivariable logistic regression analysis, pre-existing moderate (OR = 2.65, P = 0.013) and severe RV dysfunction groups (OR = 2.66, P = 0.015) were associated with statistically significant higher cardiac arrest and hemodynamic instability post intubation. Pre-existing severe RV dysfunction was associated with statistically significant higher in hospital mortality (62.35%-P < 0.001). The multivariable Cox-regression analysis showed that pre-existing severe RV dysfunction was associated with a statistically significant higher 60-day mortality (HR = 2.57, P = 0.001). Conclusions Pre-existing moderate and severe RV dysfunctions were independently associated with significantly higher cardiac arrest and/or hemodynamic instability post intubation in critically ill patients. Pre-existing RV function may serve as a mortality predictor in critically ill patients undergoing endotracheal intubation.

Managing the Physiologically Difficult Airway in Critically Ill Adults

“…Halliday et al identified hypotension, the need for vasopressors prior to intubation, age, and cirrhosis as the top four risk factors in a secondary analysis of trial data [10][11][12][13]. Right ventricular (RV) dysfunction is also an increasingly appreciated risk factor as perturbations in gas exchange, acid/base status, and intrathoracic pressure may all lead to cardiovascular collapse [14,15]. In a secondary analysis of INTUBE, the risk factors for cardiovascular instability included age, lower blood pressure, lower oxygen saturation, and propofol administration [16].…”

Airway management during resuscitation

“…To identify such patients, bedside ultrasound evaluation has been suggested. 12 While few studies have evaluated the role of transthoracic echocardiography in the critically ill patient requiring intubation, bedside transthoracic echocardiography (TTE) may reveal RV failure not clinically evident, identify wall motion abnormalities suggestive of myocardial ischemia, provide an estimate of volume status, and facilitate a diagnosis of pulmonary embolism or tamponade. Using TTE to identify patients with cardiogenic shock may then facilitate the resolution of modifiable preoperative risk factors and inform the choice of airway management technique.…”

“…A retrospective 2023 study in critically ill patients found an independent association of pre-intubation moderate to severe right ventricular dysfunction with postintubation hemodynamic instability and cardiac arrest. To identify such patients, bedside ultrasound evaluation has been suggested 12 . While few studies have evaluated the role of transthoracic echocardiography in the critically ill patient requiring intubation, bedside transthoracic echocardiography (TTE) may reveal RV failure not clinically evident, identify wall motion abnormalities suggestive of myocardial ischemia, provide an estimate of volume status, and facilitate a diagnosis of pulmonary embolism or tamponade.…”