Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study (original) (raw)
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Incidence of and Risk Factors For Post-Intubation Hypotension in the Critically Ill
Medical science monitor : international medical journal of experimental and clinical research, 2016
BACKGROUND We aim to report the incidence of post-intubation hypotension in the critically ill, to report in-hospital mortality and length of stay in those who developed post-intubation hypotension, and to explore possible risk factors associated with post-intubation hypotension. MATERIAL AND METHODS Adult (≥18 years) ICU patients who received emergent endotracheal intubation were included. We excluded patients if they were hemodynamically unstable 60 minutes pre-intubation. Post-intubation hypotension was defined as the administration of any vasopressor within 60 minutes following intubation. RESULTS Twenty-nine patients developed post-intubation hypotension (29/147, 20%). Post-intubation hypotension was associated with increased in-hospital mortality (11/29, 38% vs. 19/118, 16%) and length of stay (21 [10-37] vs. 12 [7-21] days) on multivariate analysis. Three risk factors for post-intubation hypotension were identified on multivariate analysis: 1) decreasing mean arterial pressur...
Hypotension following pre-hospital intubation: Frequent situation and inadequately corrected.
Introduction: Pre-hospital tracheal intubation is frequently performed on site by emergency medical services. Hypotension is a well-established and common complication of intubation. The aim of this study is to evaluate the frequency of hypotension, defined as a drop in systolic blood pressure below 90 mmHg following pre-hospital tracheal intubation and to evaluate the responsiveness of the medical team in correcting it. Material and methods: This is a single-center observational study including all patients intubated out-of-hospital by the emergency medical team during a 4-month period in the year 2011. The blood pressure was recorded using non-invasive monitors prior to the intubation then every 2 minutes for 30 minutes after the intubation. The evaluation of the medical charts allowed assessing the responsiveness of the medical team to hypotensive episodes. Results: Thirty-eight patients were included in the study. Mean systolic pressures dropped significantly between pre-intubation, 10 minutes and 30 minutes post intubation measurements (141 mmHg vs. 126 mmHg vs. 116 mmHg, respectively; p < 0.05). Thirty-seven percent of patients had one hypotensive episode, 21% had two episodes and 16% had more than three. They all occurred after the tenth minutes after intubation. Half of the patient had hypotension that was not noticed nor treated by the medical team. Conclusion: The occurrence of hypotension is common after tracheal intubation and occurs later than 10 minutes after intubation. Positive-pressure ventilation, sedation, and lack of vasoactive medications could be responsible for this. The detection and treatment of hypotensive episodes by the medical team were poor. Larger multicenter trials are needed to confirm these results.
Journal of Critical Care, 2015
Purpose: Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capability for postintubation hypotension in emergency department. The primary aim was to explore this relationship in the critical care environment. The secondary aims were to evaluate the relationship of shock indices with other short-term outcomes like mortality and length of stay in intensive care unit. Materials and methods: This is a nonconcurrent cohort study, conducted in eligible 140 adult intensive care unit (ICU) patients of a tertiary care medical center. Eligibility criterion was emergent endotracheal intubation in apparently hemodynamically stable patients. Results: Preintubation SI ≥ 0.90 had a significant association with postintubation hypotension as defined by systolic blood pressure b 90 mm Hg in the univariate (P = .03; odds ratio [OR], 2.13; 95% confidence interval [CI], 1.07-4.35) and multivariate analyses (P = .01; OR, 3.17; 95% CI, 1.36-7.73) after adjusting for confounders. It was also associated with higher ICU mortality in both the univariate (P = .01; OR, 4.00; 95% CI, 1.26-12.67) and multivariate analyses (P = .01; OR, 5.75; 95% CI, 1.58-26.48). There was no association of preintubation MSI with postintubation hemodynamic instability and ICU mortality. No association was found between preintubation SI and MSI, with ICU length of stay and 30-day mortality. Conclusions: Our findings indicate that preintubation SI greater than or equal to 0.90 is a predictor of postintubation hypotension (systolic blood pressure b90 mm Hg) and ICU mortality in emergently intubated adult patients in intensive care units.
Postintubation hypotension in elective surgerypatients: a retrospective study
2018
Objective. Postintubation hypotension (PIH) is a common and recognized adverse event associated with poor outcomes in emergency medicine patients requiring endotracheal intubation. Our objectives were to determine the incidence of PIH following tracheal intubation in elective surgery patients. Materials and Methods. A retrospective study by reviewing the anesthesia records of all patients presenting for elective surgery requiring tracheal intubation between February 1, 2017, and March 1, 2017 was performed. Patients were divided into 2 groups according to the severity of the operation: Group S1 (major surgery) and Group S2 (minor surgery). The primary outcome measure was the incidence of PIH. PIH was claimed when systolic blood pressure (SBP) decreased below 90 mm Hg or decreased more than 20% from the baseline in two consecutive measurements at least 15 minutes after intubation. Secondary outcome measures included the relationship between PIH and anesthetic induction agents used to...
Prevalence and Predictors of Post-Intubation Hypotension in Prehospital Trauma Care
Prehospital Emergency Care, 2019
Prehospital care of severe trauma patients often involves endotracheal intubation (ETI), which has complications. The frequency and predictors of post-ETI hypotension and cardiac arrest are not well defined in this population. We sought to derive and validate a scoring system that predicts post-ETI hypotension in prehospital patients and to describe the impact of hypotension on outcome. We performed an observational cohort study including normotensive adult trauma patients requiring ETI, treated from 2001 to 2018 by critical care transport providers in a regional air medical transport system. We divided eligible patients into a derivation cohort (2001-2010) and validation cohort (2011-2018) for analysis. We identified predictors of new systolic hypotension (<90 mmHg) or cardiac arrest within 15 minutes of ETI then developed and validated a scoring system that stratified patients into low, moderate and high risk. We included 4,866 subjects, 3,127 in the derivation and 1,739 in the validation cohort. Post-ETI hypotension occurred in 11% and 21%, respectively; 5% of each cohort experienced post-ETI cardiac arrest. Major independent predictors of post-ETI hypotension were age, pre-ETI systolic blood pressure and pre-ETI oxygen saturation. We developed a well-calibrated scoring system based on these major and several minor risk factors. Applying our system, 890 (33%) derivation patients and 550 (37%) validation patients were higher risk for post-ETI adverse outcomes. Of these, 21% and 33% respectively experienced post-ETI hypotension and 6% and 4% respectively suffered post-ETI cardiac arrest. Patients at high risk for post-ETI hypotension or arrest are common and identifiable in prehospital trauma care.
The prognostic factors of hypotension after rapid sequence intubation
The American Journal of Emergency Medicine, 2008
Background: Rapid sequence intubation (RSI) has achieved high success and low complication rate in the ED. However, hypotension after RSI does occur. This study aimed to identify the prognostic factors of hypotension after RSI. Methods: This study identified patients who needed emergency airway management and then divided them into 2 groups. Patients in the first group were the hypotension group, whose systolic blood pressure (SBP) was found to be greater than 90 mm Hg before RSI but less than 90 mm Hg after RSI. Patients in the second group were deemed as the control group whose pre-SBP and post-SBP were greater than 90 mm Hg. The following variables were measured in the study: age, sex, body weight, patients' underlying disease and ongoing disease, the initial vital signs, and laboratory tests. A prognostic model with multiple logistic regression was established based on significant findings from univariate analysis. Results: A total of 149 patients were recruited from the ED in this study, with 28 patients in the hypotension group and 121 patients in the control group. After univariate analysis, there were 6 factors identified as significant findings including chronic obstructive pulmonary disease, sepsis, albumin, lidocaine, low body weight (b55 kg), and preintubation blood pressure of less than 140 mm Hg. Multiple logistic regression has demonstrated that patients' underlying diseases, anthropometric parameters, and drug medications were factors related to postintubation hypotension among ED patients. Conclusions: Clinical practitioners in the ED should take a patient's predisposing factors into serious consideration before emergency intubation while a preplanned strategy is made.
Postprandial hypotension in older survivors of critical illness
Journal of critical care, 2018
In older people postprandial hypotension occurs frequently; and is an independent risk factor for falls, cardiovascular events, stroke and death. The primary aim of this pilot study was to estimate the frequency of postprandial hypotension and evaluate the mechanisms underlying this condition in older survivors of an Intensive Care Unit (ICU). Thirty-five older (>65 years) survivors were studied 3 months after discharge. After an overnight fast, participants consumed a 300 mL drink containing 75 g glucose, labelled with 20 MBq 99mTc-calcium phytate. Patients had concurrent measurements of blood pressure, heart rate, blood glucose and gastric emptying following drink ingestion. Proportion of participants is presented as percent (95% CI) and continuous variables as mean (SD). Postprandial hypotension was evident in 10 (29%; 95% CI 14-44), orthostatic hypotension in 2 (6%; 95% CI 0-13) and cardiovascular autonomic dysfunction in 2 (6%; 95% CI 0-13) participants. The maximal postpran...
Risk Factors for and Prediction of Hypoxemia during Tracheal Intubation of Critically Ill Adults
Annals of the American Thoracic Society
Rationale: Hypoxemia is a common complication during tracheal intubation of critically ill adults and is a frequently used endpoint in airway management research. Identifying patients likely to experience low oxygen saturations during tracheal intubation may be useful for clinical practice and clinical trials. Objectives: To identify risk factors for lower oxygen saturations and severe hypoxemia during tracheal intubation of critically ill adults and develop prediction models for lowest oxygen saturation and hypoxemia. Methods: Using data on 433 intubations from two randomized trials, we developed linear and logistic regression models to identify preprocedural risk factors for lower arterial oxygen saturations and severe hypoxemia between induction and 2 minutes after intubation. Penalized regression was used to develop prediction models for lowest oxygen saturation after induction and severe hypoxemia. A simplified six-point score was derived to predict severe hypoxemia. Results: Among the 433 intubations, 426 had complete data and were included in the model. The mean (standard deviation) lowest oxygen saturation was 88% (14%); median (interquartile range) was 93% (83-98%). Independent predictors of severe hypoxemia included hypoxemic respiratory failure as the indication for intubation (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.58-4.60), lower oxygen saturation at induction (OR, 0.92 per 1% increase; 95% CI, 0.89-0.96 per 1% increase), younger age (OR, 0.97 per 1-year increase; 95% CI, 0.95-0.99 per 1-year increase), higher body mass index (OR, 1.03 per 1 kg/m 2 ; 95% CI, 1.00-1.06 per 1 kg/m 2), race (OR, 4.58 for white vs. black; 95% CI, 1.97-10.67; OR, 4.47 for other vs. black; 95% CI, 1.19-16.84), and operator with fewer than 100 prior intubations (OR, 2.83; 95% CI, 1.37-5.85). A six-point score using the identified risk factors predicted severe hypoxemia with an area under the receiver operating curve of 0.714 (95% CI, 0.653 to 0.778). Conclusions: Lowest oxygen saturation and severe hypoxemia during tracheal intubation in the intensive care unit can be accurately predicted using routinely available preprocedure clinical data, with saturation at induction and hypoxemic respiratory failure being the strongest predictors. A simple bedside score may identify patients at risk for hypoxemia during intubation to help target preventative interventions and facilitate enrichment in clinical trials.
Critical Care, 2009
Introduction Central venous oxygen saturation (ScvO2) has emerged as an important resuscitation goal for critically ill patients. Nevertheless, growing concerns about its limitations as a perfusion parameter have been expressed recently, including the uncommon finding of low ScvO2 values in patients in the intensive care unit (ICU). Emergency intubation may induce strong and eventually divergent effects on the physiologic determinants of oxygen transport (DO2) and oxygen consumption (VO2) and, thus, on ScvO2. Therefore, we conducted a study to determine the impact of emergency intubation on ScvO2. Methods In this prospective multicenter observational study, we included 103 septic and non-septic patients with a central venous catheter in place and in whom emergency intubation was required. A common intubation protocol was used and we evaluated several parameters including ScvO2 before and 15 minutes after emergency intubation. Statistical analysis included chi-square test and t test. Results ScvO2 increased from 61.8 ± 12.6% to 68.9 ± 12.2%, with no difference between septic and non-septic patients. ScvO2 increased in 84 patients (81.6%) without correlation to changes in arterial oxygen saturation (SaO2). Seventy eight (75.7%) patients were intubated with ScvO2 less than 70% and 21 (26.9%) normalized the parameter after the intervention. Only patients with pre-intubation ScvO2 more than 70% failed to increase the parameter after intubation. Conclusions ScvO2 increases significantly in response to emergency intubation in the majority of septic and non-septic patients. When interpreting ScvO2 during early resuscitation, it is crucial to consider whether the patient has been recently intubated or is spontaneously breathing.