Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

Smischney, Nathan J.; Kashyap, Rahul; Khanna, Ashish K.; Brauer, Ernesto; Morrow, Lee E.; Seisa, Mohamed O.; Schroeder, Darrell R.; Diedrich, Daniel A.; Montgomery, Ashley; Franco, Pablo Moreno; Ofoma, Uchenna R.; Kaufman, David A.; Sen, Ayan; Callahan, Charles D.; Venkata, Chakradhar; Demiralp, Gozde; Tedja, Rudy; Lee, Sarah; Geube, Mariya; Kumar, Shubha; Morris, Peter E.; Bansal, Vikas; Surani, Salim

doi:10.1371/journal.pone.0233852

Cited by 42 publications

(46 citation statements)

References 35 publications

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“…No specific recommendations for type of vasopressor support have been suggested in the literature, though the use of pharmacotherapy to increase afterload and or inotropy during and after the procedure has been articulated [46]. A systolic blood pressure of <130 mmHg prior to intubation is associated with postintubation hypotension in critically ill patients and this threshold will likely apply to COVID19 patients as well [40]. Vasopressor rescue or push doses should be available at the times of intubation, and may include phenylephrine, ephedrine, norepinephrine, and or epinephrine depending on clinical assessment, severity and needs.…”

Section: Hemodynamic Optimizationmentioning

confidence: 99%

Airway management in the critically ill patient with COVID-19

Jong¹,

Khanna

2022

Current Opinion in Anaesthesiology

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Purpose of reviewCritically ill Coronavirus disease 2019 patients needing endotracheal intubation are on the verge of rapid decompensation. The aims of this review were to assess the risks, the preoxygenation, the device and the hemodynamic management of a patient with COVID-19. Recent findingsThe proceduralist performing endotracheal intubation with the entire team are at an increased risk for exposure to COVID-19. Appropriate personal protective equipment and other measures remain essential. For preoxygenation, noninvasive ventilation allows higher oxygen saturation during intubation in severely hypoxemic patients and can be associated with apneic oxygenation and mask ventilation during apnea in selected cases. The COVID-19 pandemic has further highlighted the place of videolaryngoscopy during intubation in intensive care unit (ICU). Hemodynamic optimization is mandatory to limit hypotension and cardiac arrest associated with airway management. SummaryFuture trials will better define the role of videolaryngoscopy, apneic oxygenation and mask ventilation during apnea for intubation of COVID-19 patients in ICU. The use of fluid loading and vasopressors remains to be investigated in large randomized controlled studies. Choosing the right time for intubation remains uncertain in clinical practice, and future works will probably help to identify earlier the patients who will need intubation.

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Section: Hemodynamic Optimizationmentioning

confidence: 99%

Airway management in the critically ill patient with COVID-19

Jong¹,

Khanna

2022

Current Opinion in Anaesthesiology

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“…An elevated shock index is a specific but insensitive marker of post-intubation hypotension [ 45 – 47 , 50 – 53 ]. Recent regression analyses and two recent prediction scores have been developed, which all find that in general, older age, hypotension or shock prior to intubation, intubation for respiratory failure, and higher APACHE score are all strong predictors of post-intubation cardiovascular collapse [ 52 , 54 – 56 ].…”

Section: Hemodynamicsmentioning

confidence: 99%

Airway Management in the Critically Ill Patient

Mosier

2021

Curr Anesthesiol Rep

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Purpose of Review This paper will evaluate the recent literature and best practices in airway management in critically ill patients. Recent Findings Cardiac arrest remains a common complication of intubation in these high-risk patients. Patients with desaturation or peri-intubation hypotension are at high risk of cardiac arrest, and each of these complications have been reported in up to half of all intubations in critically ill patient populations. Summary There have been significant advances in preoxygenation and devices available for performing laryngoscopy and rescue oxygenation. However, the risk of cardiovascular collapse remains concerningly high with few studies to guide therapeutic maneuvers to reduce this risk.

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“…The investigators identified 11 variables (increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure < 65 mmHg, and acute respiratory failure; diuretic use 24 h preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine or phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation) that were independently associated with peri-intubation hypotension with a C-statistic of 0.75 [95% confidence interval (CI): 0.72-0.78]. Of the 11 variables, the use of etomidate was found to protect against peri-intubation hypotension[ 3 ].…”

Section: Introductionmentioning

confidence: 99%

Endotracheal intubation sedation in the intensive care unit

Tarwade¹,

Smischney²

2022

WJCCM

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Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.

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Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

Abstract: investigators are given in S1 Table.

Cited by 42 publications

References 35 publications

Airway management in the critically ill patient with COVID-19

Airway management in the critically ill patient with COVID-19

Airway Management in the Critically Ill Patient

Endotracheal intubation sedation in the intensive care unit

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