Elsevier

Journal of Critical Care

Volume 27, Issue 4, August 2012, Pages 417.e9-417.e13
Journal of Critical Care

Ventilation
The frequency and significance of postintubation hypotension during emergency airway management

https://doi.org/10.1016/j.jcrc.2011.08.011Get rights and content

Abstract

Objective

Arterial hypotension is a recognized complication of emergency intubation, but the consequence of this event is poorly described. Our aim was to identify the incidence of postintubation hypotension (PIH) after emergency intubation and to determine its association with inhospital mortality.

Methods

Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements less than 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with PIH, defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. The primary outcome was inhospital mortality.

Results

Of 465 patients who underwent emergency intubation, 336 met inclusion criteria and were analyzed. Postintubation hypotension occurred in 79 (23%) of 336 patients. Patients with PIH had significantly higher inhospital mortality (33% vs 21%; 95% confidence interval for 12% difference, 1%-23%) and longer mean intensive care length of stay (LOS) (9.7 vs 5.9 days, P < .01) and hospital LOS (17.0 vs 11.4 days, P < .01). Postintubation hypotension remained a significant predictor of inhospital mortality after adjusting for confounding using multivariable logistic regression analysis (odds ratio, 1.9; 95% confidence interval, 1.1-3.5).

Conclusion

Postintubation hypotension occurs in almost one quarter of normotensive patients undergoing emergency intubation. Postintubation hypotension is independently associated with higher inhospital mortality and longer intensive care unit and hospital LOS.

Introduction

Emergency airway management is fundamental to the care of critically ill patients. The use of a rapid acting hypnotic and neuromuscular blocking agent, collectively referred to as rapid sequence intubation (RSI), is widely considered the standard technique to facilitate emergency endotracheal intubation. Technical difficulties including procedural failure, esophageal intubation, pulmonary aspiration, and hypoxemia are the most commonly recognized immediate complications of RSI.

Arterial hypotension is generally considered a late sign of cardiovascular insufficiency that occurs once compensatory mechanisms to maintain blood pressure are overwhelmed or exhausted [1]. Transient and persistent hypotension are associated with mortality and organ dysfunction during acute illness [2], [3]. Accordingly, preintubation hypotension has been associated with severe complications and death after emergency airway control [4], [5].

Presently, there are conflicting data on the frequency of hemodynamic deterioration after emergency intubation, with some authors suggesting it is a rare complication [6], [7], [8] and others reporting it is relatively common [5], [9], [10], [11]. However, no study has reported the direction and magnitude of effect of postintubation hypotension (PIH) on mortality. Although arterial hypotension typically triggers aggressive resuscitative efforts, hypotension has been described as a physiologic response to intubation due to multiple mechanisms including induction-associated sympatholysis and the effects of positive-pressure ventilation [12], [13]. In the absence of data to determine effect, clinicians may assume that PIH is a benign, transient, or self-limited consequence of airway management [14]. We aimed to quantify the hemodynamic consequences of emergency intubation by studying the incidence and risk associated with PIH. Our hypothesis was that PIH after emergency intubation is associated with significantly higher inhospital mortality as compared with hemodynamic stability after intubation.

Section snippets

Study design and setting

We conducted a retrospective cohort study of consecutive patients requiring emergency airway management from January 1, 2007, to December 31, 2007, in the emergency department (ED) at Carolinas Medical Center, a large, urban teaching hospital with more than 100 000 patient visits per year. This ED is staffed by emergency medicine residents supervised by board-certified emergency physicians. All attending physicians are privileged for emergency airway management. Dedicated training in emergency

Results

We identified 542 patients who underwent ED endotracheal intubation during 2007, and 336 patients were analyzed in this study (Fig. 1). The demographic and clinical characteristics of the study subjects are shown in Table 1. Two independent reviewers had excellent agreement for the determination of the variable of PIH present or absent (κ = 0.85; 95% CI, 0.61-1.0). Most patients received etomidate and succinylcholine for RSI. Postintubation hypotension was observed in 79 (23%; 95% CI, 19-28) of

Discussion

In this study, we document that PIH occurs in nearly one quarter of patients who are hemodynamically stable before intubation and that PIH is associated with inhospital mortality. Furthermore, among survivors, PIH is associated with significantly prolonged ICU and hospital LOS. When controlling for other variables, PIH is an independent predictor of inhospital mortality. We believe this to be the first study to show this association.

Our study adds to the body of literature highlighting

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    None of the authors have a conflict of interest to report.

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