Skip to main content
×
×
Home

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

  • Robert S. Green (a1) (a2) (a3), Janet Edwards (a4), Elham Sabri (a3) (a5) and Dean Fergusson (a3) (a5)
Abstract
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.

    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability
      Available formats
      ×
Copyright
Corresponding author
Room 377 Bethune Building, 1276 South Park Street, Halifax, NS, B3H 2Y9
References
Hide All
1.Kharasch, M, Graff, J. Emergency management of the airway. Crit Care Clin 1995;11:5366.
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.
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.
4.Part 4: Advanced life support. Circulation 2005;112(22 Suppl):III–25–54.
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.
6.Walz, JM, Zayaruzny, M, Heard, SO. Airway management in critical illness. Chest 2007;131:608–20, doi:10.1378/chest.06-2120.
7.Langeron, O, Amour, J, Vivien, B, Aubrun, F. Clinical review: management of difficult airways. Crit Care 2006;10:243, doi:10.1186/cc5112.
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.
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.
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.
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.
12.Mort, TC. Complications of emergency tracheal intubation: hemodynamic alterations—part I. J Intensive Care Med 2007;22:157–65, doi:10.1177/0885066607299525.
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.
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.
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;21:296301.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
29.Graham, CA, Beard, D, Oglesby, AJ, et al. Rapid sequence intubation in Scottish urban emergency departments. Emerg Med J 2003;20:35, doi:10.1136/emj.20.1.3.
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.
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.
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.
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.
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;43:4853, doi:10.1016/S0196-0644(03)00638-3.
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.
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.
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.
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.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Canadian Journal of Emergency Medicine
  • ISSN: -
  • EISSN: 1481-8035
  • URL: /core/journals/canadian-journal-of-emergency-medicine
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 176 *
Loading metrics...

Abstract views

Total abstract views: 180 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 16th August 2018. This data will be updated every 24 hours.