VentilationThe frequency and significance of postintubation hypotension during emergency airway management☆
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.
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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.