Risk factors for hypotension in urgently intubated burn patients

Dennis, Christopher J.; Chung, Kevin K.; Holland, Seth R.; Yoon, Brian; Milligan, Daun J.; Nitzschke, Stephanie; Maani, Christopher V.; Hansen, Jacob J.; Aden, James K; Renz, Evan M.

doi:10.1016/j.burns.2012.07.004

Cited by 6 publications

(6 citation statements)

References 13 publications

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“…In our study, patients who received prophylactic vasopressors were also older, had higher severity of illness scores, had lower pre-induction systolic blood pressures, and were more likely to be receiving vasopressor infusions before intubation. These characteristics match previously described risk factors for peri-intubation hypotension (8, 10–12, 29, 30, 38), suggesting that clinicians tend to administer prophylactic vasopressors to patients assessed to be at higher risk of experiencing peri-intubation hypotension. Future study designs may benefit from using these factors for prognostic enrichment (39).…”

Section: Discussionsupporting

confidence: 82%

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Fuchita

Pattee

Russell

et al. 2023

Critical Care Explorations

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OBJECTIVE: Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN: A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING: Seven emergency departments and 17 ICUs across the United States. PATIENTS: One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (–12 vs –11 mm Hg; p = 0.66). CONCLUSIONS: The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.

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Section: Discussionsupporting

confidence: 82%

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Fuchita

Pattee

Russell

et al. 2023

Critical Care Explorations

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“…Based on the above literature review, we included six surrogate 171 markers for which we believe correctly identified all critically ill patients developing hemodynamic compromise [ 5 – 12 ]. The six markers included (1) any SBP ≤90 mmHg 60 min post-intubation, (2) any MAP ≤65 mmHg 60 min post-intubation, (3) reduction in median SBP of ≥20 % 60 min post-intubation, (4) any vasopressor administration 60 min post-intubation, (5) any non-sinus rhythm 60 min post-intubation, and (6) fluid administration (crystalloid and/or colloid) of ≥30 ml/kg 60 min post-intubation.…”

Section: Methodsmentioning

confidence: 99%

“…Most of the current information on post-intubation hemodynamic instability comes from the emergency department [ 6 , 8 , 10 , 11 ]. Studies based in the intensive care unit (ICU) setting found a relationship between post-intubation hemodynamic instability and increased morbidity and mortality; however, these studies failed to establish concrete definitions and validated predictors for mortality or increased length of stay [ 5 , 7 , 12 ].…”

Section: Introductionmentioning

confidence: 99%

Vasopressor use as a surrogate for post-intubation hemodynamic instability is associated with in-hospital and 90-day mortality: a retrospective cohort study

et al. 2015

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BackgroundEvidence is lacking for what defines post-intubation hypotension in the intensive care unit (ICU). If a valid definition could be used, the potential exists to evaluate possible risk factors and thereby improve post-intubation. Thus, our objectives were to arrive at the best surrogate for post-intubation hypotension that accurately predicts both in-hospital and 90-day mortality in a population of ICU patients and to report mortality rates between the exposed and unexposed cohorts.MethodsWe conducted a retrospective cohort study of emergent endotracheal intubations in a medical-surgical ICU from January 1, 2010 to December 31, 2011 to evaluate surrogates for post-intubation hypotension that would predict in-hospital and 90-day mortality followed by an analysis of exposed versus unexposed using our best surrogate. Patients were ≥18 years of age, underwent emergent intubation during their first ICU admission, and did not meet any of the surrogates 60 min pre-intubation.ResultsThe six surrogates evaluated 60 min post-intubation were those with any systolic blood pressures ≤90 mmHg, any mean arterial pressures ≤65 mmHg, reduction in median systolic blood pressures of ≥20 %, any vasopressor administration, any non-sinus rhythm and, fluid administration of ≥30 ml/kg. A total of 147 patients were included. Of the six surrogates, only the administration of any vasopressor 60 min post-intubation remained significant for mortality. Twenty-nine patients were then labeled as hemodynamically unstable and compared to the 118 patients labeled as hemodynamically stable. After adjusting for confounders, the hemodynamically unstable group had a significantly higher in-hospital and 90-day mortality [OR (95 % CI); 3.84 (1.31–11.57) (p value = 0.01) and 2.37 (1.18–4.61) (p-value = 0.02)].ConclusionsEmergently intubated patients manifesting hemodynamic instability after but not before intubation, as measured by vasoactive administration 60 min post-intubation, have a higher association with in-hospital and 90-day mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/s13104-015-1410-7) contains supplementary material, which is available to authorized users.

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“…The ICU population is significantly different from the operating room population, primarily due to the incidence of sepsis and suspected sepsis and associated reduced systemic vascular resistance, as well as increased circulation of inflammatory mediators. The diagnosis of sepsis has been described as a risk factor for intubation requirement [ 28 ], as the single culprit of hypotension in burn patients [ 29 ], and as a predictor of mortality if documented during the immediate period prior to intubation [ 5 ]. Given the association of sepsis and poor prognosis after orotracheal intubation, combined with the physiological knowledge that sepsis causes decreased SVR, we hypothesize that the combination of ketamine and propofol should be expanded from the ED and operating room to the ICU.…”

Section: Discussionmentioning

confidence: 99%

Ketamine and Propofol Combination (“Ketofol”) for Endotracheal Intubations in Critically Ill Patients: A Case Series

et al. 2015

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Case seriesPatient: Male, 77 • Male, 25 • Male, 63 • Male, 70 • Male, 70 • Female, 61Final Diagnosis: —Symptoms: Hypotension • respiratory failureMedication: Ketamine • Propofol • EtomidateClinical Procedure: Endotracheal intubationSpecialty: Critical Care MedicineObjective:Educational Purpose (only if useful for a systematic review or synthesis)Background:Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation.Case Series:We describe 6 cases in which the combination of ketamine and propofol (“ketofol”) was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations.Conclusions:This case series describes the use of the “ketofol” combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.

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Risk factors for hypotension in urgently intubated burn patients

Cited by 6 publications

References 13 publications

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Vasopressor use as a surrogate for post-intubation hemodynamic instability is associated with in-hospital and 90-day mortality: a retrospective cohort study

Ketamine and Propofol Combination (“Ketofol”) for Endotracheal Intubations in Critically Ill Patients: A Case Series

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