Hostname: page-component-78c5997874-v9fdk Total loading time: 0 Render date: 2024-11-13T06:18:05.744Z Has data issue: false hasContentIssue false
  • English
  • Français

Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability

Published online by Cambridge University Press:  11 May 2015

Robert S. Green ,
Janet Edwards ,
Elham Sabri  and
Dean Fergusson
Robert S. Green*
Affiliation:
Department of Emergency Medicine, Dalhousie University, Halifax, NS Division of Critical Care Medicine, Department of Anesthesia, Dalhousie University, Halifax, NS Ottawa Center for Transfusion Research, Ottawa, ON
Janet Edwards
Affiliation:
Department of Surgery, University of Calgary, Calgary, AB
Elham Sabri
Affiliation:
Ottawa Center for Transfusion Research, Ottawa, ON Ottawa Health Research Institute, Ottawa, ON
Dean Fergusson
Affiliation:
Ottawa Center for Transfusion Research, Ottawa, ON Ottawa Health Research Institute, Ottawa, ON
*
Room 377 Bethune Building, 1276 South Park Street, Halifax, NS, B3H 2Y9

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine.

Methods:

A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≥ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation.

Results:

Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01–1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19–7.57), and pre–emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27–4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16–0.75).

Conclusions:

Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.

Keywords

adverse eventsairwayepidemiologyhypotensionintubation
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 14 , Issue 2 , March 2012 , pp. 74 - 82
Copyright
Copyright © Canadian Association of Emergency Physicians 2012

References

REFERENCES

1.Kharasch, M, Graff, J. Emergency management of the airway. Crit Care Clin 1995;11:5366.CrossRefGoogle ScholarPubMed
2.Mort, TC. Anesthesia practice in the emergency department: overview, with a focus on airway management. Curr Opin Anaesthesiol 2007;20:373–8, doi:10.1097/ACO.0b013e32825eabe7.CrossRefGoogle ScholarPubMed
3.Shuster, M, Nolan, J, Barnes, TA. Airway and ventilation management. Cardiol Clin 2002;20:23–35, doi:10.1016/S0733-8651(03)00063-8.CrossRefGoogle ScholarPubMed
4.Part 4: Advanced life support. Circulation 2005;112(22 Suppl):III–25–54.Google Scholar
5.Diamond, LM. Cardiopulmonary resuscitation and acute cardiovascular life support—a protocol review of the updated guidelines. Crit Care Clin 2007;23:873–80, vii, doi:10.1016/j.ccc.2007.08.001.CrossRefGoogle ScholarPubMed
6.Walz, JM, Zayaruzny, M, Heard, SO. Airway management in critical illness. Chest 2007;131:608–20, doi:10.1378/chest.06-2120.CrossRefGoogle ScholarPubMed
7.Langeron, O, Amour, J, Vivien, B, Aubrun, F. Clinical review: management of difficult airways. Crit Care 2006;10:243, doi:10.1186/cc5112.CrossRefGoogle ScholarPubMed
8.Idris, AH, Gabrielli, A. Advances in airway management. Emerg Med Clin North Am 2002;20:843–57, ix, doi:10.1016/S0733-8627(02)00031-7.CrossRefGoogle ScholarPubMed
9.Fasting, S, Gisvold, SE. Serious intraoperative problems—a five-year review of 83,844 anesthetics. Can J Anaesth 2002;49:545–53, doi:10.1007/BF03017379.CrossRefGoogle Scholar
10.Domino, KB, Posner, KL, Caplan, RA, Cheney, FW. Airwayinjury during anesthesia: a closed claims analysis. Anesthesiology 1999;91:1703–11, doi:10.1097/00000542-199912000-00023.CrossRefGoogle ScholarPubMed
11.Mort, TC. Complications of emergency tracheal intubation: immediate airway-related consequences: part II. J Intensive Care Med 2007;22:208–15, doi:10.1177/0885066607301359.CrossRefGoogle ScholarPubMed
12.Mort, TC. Complications of emergency tracheal intubation: hemodynamic alterations—part I. J Intensive Care Med 2007;22:157–65, doi:10.1177/0885066607299525.CrossRefGoogle ScholarPubMed
13.Franklin, C, Samuel, J, Hu, TC. Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation. Am J Emerg Med 1994;12:425–8, doi:10.1016/0735-6757(94)90053-1.CrossRefGoogle ScholarPubMed
14.Jaber, S, Amraoui, J, Lefrant, JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 2006;34:2355–61, doi:10.1097/01.CCM.0000233879.58720.87.CrossRefGoogle ScholarPubMed
15.Reid, C, Chan, L, Tweeddale, M. The who where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre, Emerg Med J 2004;21:296–301.CrossRefGoogle ScholarPubMed
16.Jones, AE, Yiannibas, V, Johnson, C, Kline, JA. Emergency department hypotension predicts sudden unexpected inhospital mortality: a prospective cohort study. Chest 2006;130:941–6, doi:10.1378/chest.130.4.941.CrossRefGoogle ScholarPubMed
17.Lalezarzadeh, F, Wisniewski, P, Huynh, K, et al. Evaluation of prehospital and emergency department systolic blood pressure as a predictor of in-hospital mortality. Am Surg 2009;75:1009–14.CrossRefGoogle ScholarPubMed
18.Schreiber, MA, Aoki, N, Scott, BG, Beck, JR. Determinants of mortality in patients with severe blunt head injury. Arch Surg 2002;137:285–90, doi:10.1001/archsurg.137.3.285.CrossRefGoogle ScholarPubMed
19.Sakles, JC, Laurin, EG, Rantapaa, AA, Panacek, EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998;31:325–32,doi:10.1016/S0196-0644(98)70342-7.CrossRefGoogle ScholarPubMed
20.Tayal, VS, Riggs, RW, Marx, JA, et al. Rapid-sequence intubation at an emergency medicine residency: success rate and adverse events during a two-year period. Acad Emerg Med 1999;6:31–7, doi:10.1111/j.1553-2712.1999.tb00091.x.CrossRefGoogle ScholarPubMed
21.Griesdale, DE, Bosma, TL, Kurth, T, et al. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34:1835–42, doi:10.1007/s00134-008-1205-6.CrossRefGoogle ScholarPubMed
22.Mort, TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 2004;99:607–13, doi:10.1213/01.ANE.0000122825.04923.15.CrossRefGoogle ScholarPubMed
23.Dufour, DG, Larose, DL, Clement, SC. Rapid sequence intubation in the emergency department. J Emerg Med 1995;13:705–10, doi:10.1016/0736-4679(95)00089-S.CrossRefGoogle ScholarPubMed
24.Choi, YF, Wong, TW, Lau, CC. Midazolam is more likely to cause hypotension than etomidate in emergency department rapid sequence intubation. Emerg Med J 2004;21:700–2, doi:10.1136/emj.2002.004143.CrossRefGoogle ScholarPubMed
25.Tam, AY, Lau, FL. A prospective study of tracheal intubation in an emergency department in Hong Kong. Eur J Emerg Med 2001;8:305–10, doi:10.1097/00063110-200112000-00011.CrossRefGoogle Scholar
26.Marvez, E, Weiss, SJ, Houry, DE, Ernst, AA. Predicting adverse outcomes in a diagnosis-based protocol system for rapid sequence intubation. Am J Emerg Med 2003;21:23–9, doi:10.1053/ajem.2003.50002.CrossRefGoogle Scholar
27.Wong, E, Fong, YT, Ho, KK. Emergency airway management—experience of a tertiary hospital in South-east Asia. Resuscitation 2004;61:349–55, doi:10.1016/j.resuscitation.2004.01.011.CrossRefGoogle ScholarPubMed
28.Wong, E, Fong, YT. Trauma airway experience by emergency physicians. Eur J Emerg Med 2003;10:209–12, doi:10.1097/00063110-200309000-00010.CrossRefGoogle ScholarPubMed
29.Graham, CA, Beard, D, Oglesby, AJ, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2003;20:3–5, doi:10.1136/emj.20.1.3.CrossRefGoogle ScholarPubMed
30.Sivilotti, ML, Ducharme, J. Randomized, double-blind study on sedatives and hemodynamics during rapid-sequence intubation in the emergency department: the SHRED study Ann Emerg Med 1998;31:313–24, doi:10.1016/S0196-0644(98)70341-5.CrossRefGoogle ScholarPubMed
31.Lin, CC, Chen, KF, Shih, CP, et al. The prognostic factors of hypotension after rapid sequence intubation. Am J Emerg Med 2008;26:845–51, doi:10.1016/j.ajem.2007.11.027.CrossRefGoogle ScholarPubMed
32.Omert, L, Yeaney, W, Mizikowski, S, Protetch, J. Role of the emergency medicine physician in airway management of the trauma patient. J Trauma 2001;51:1065–8, doi:10.1097/00005373-200112000-00007.Google ScholarPubMed
33.Li, J, Murphy-Lavoie, H, Bugas, C, et al. Complications of emergency intubation with and without paralysis. Am J Emerg Med 1999;17:141–3, doi:10.1016/S0735-6757(99)90046-3.CrossRefGoogle ScholarPubMed
34.Levitan, RM, Rosenblatt, B, Meiner, EM, et al. Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success. Ann Emerg Med 2004;43:48–53, doi:10.1016/S0196-0644(03)00638-3.CrossRefGoogle ScholarPubMed
35.Sagarin, MJ, Barton, ED, Chng, YM, Walls, RM, National Emergency Airway Registry Investigators. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005;46:328–36, doi:10.1016/j.annemergmed.2005.01.009.CrossRefGoogle Scholar
36.Zed, PJ, Abu-Laban, RB, Harrison, DW. Intubating conditions and hemodynamic effects of etomidate for rapid sequence intubation in the emergency department: an observational cohort study. Acad Emerg Med 2006;13:378–83, doi:10.1111/j.1553-2712.2006.tb00313.x.CrossRefGoogle ScholarPubMed
37.Smith, DC, Bergen, JM, Smithline, H, Kirschner, R. A trial of etomidate for rapid sequence intubation in the emergency department. J Emerg Med 2000;18:13–6, doi:10.1016/S0736-4679(99)00154-7.CrossRefGoogle ScholarPubMed
38.Kovacs, G, Law, JA, Ross, J, et al. Acute airway management in the emergency department by non-anesthesiologists. Can J Anaesth 2004;51:174–80, doi:10.1007/BF03018780.CrossRefGoogle ScholarPubMed