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

Abstract

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.

Risk factors associated with inpatient cardiac arrest during emergency endotracheal intubation at general wards

“…However, there have been few studies of peri-intubation cardiac arrest (PICA) [5][6][7]. The development of postintubation hypotension is increasingly recognized as a complication independently associated with morbidity and mortality [8,9]. Taken together, these facts highlight the need for additional evidence and insights into hemodynamic instability following endotracheal intubation (ETI).…”

Republication: All India Difficult Airway Association 2016 Guidelines for Tracheal Intubation in the Intensive Care Unit

“…[33] Peri-intubation hemodynamic instability has been shown to increase ICU stay and hospital mortality. [3133343536] These studies highlight the importance of fluid resuscitation in critically ill patients along with preoxygenation, to improve the safety of emergency intubations. In addition, preparedness and prompt treatment of postintubation hypotension with vasopressors and further fluid therapy are important.…”

Strategies to improve first attempt success at intubation in critically ill patients

“…When patients required vasopressors within 60 min of intubation, there were even higher odds of in-hospital death (3.84; 95% CI: 1.31-11.57) and a mortality of 38%. 73 Predicting those who will develop post-intubation hypotension has proved difficult. Similar to data from the emergency department, 74 a pre-intubation shock index (heart rate/systolic blood pressure) >0.90 had an odds ratio of 3.17 (95% CI 1.36-7.73) of developing post-intubation hypotension.…”