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Postintubation Hypotension in General Anesthesia: A Retrospective Analysis

BACKGROUND

Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department endotracheal intubations. Study objective was to determine the incidence of PIH and its impact on outcomes following tracheal intubation in a general anesthesia population.

METHODS

Structured chart audit of adult patients intubated for a vascular surgery procedure at a tertiary care center over a 3-year period. Outcomes included in-hospital mortality, extended intensive care unit length of stay (ICU LOS), and requirement for postoperative (postop) hemodialysis or mechanical ventilation.

RESULTS

Incidence of PIH was 60% (837 of 1395). Patients who developed PIH had increased mortality (8.8% PIH vs 5.2% no-PIH; P = .014), extended ICU LOS (7.9% PIH vs 2.0% no-PIH; P < .001), and postop mechanical ventilation requirement (20.7% PIH vs 3.8% no-PIH; P < .001). When controlling for confounding factors, PIH was associated with extended ICU LOS (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.01-6.62, P = .049), postop ventilation (OR 2.43, 95% CI 1.27-4.74, P = .008), and a composite end point (OR 1.72, 95% CI 1.02-2.92, P = .043).

CONCLUSIONS

Development of PIH occurs in 60% of patients undergoing intubation for vascular surgery and was associated with adverse outcomes including extended ICU LOS and postop ventilation requirement.

Incidence of postintubation hemodynamic instability associated with emergent intubations performed outside the operating room: a systematic review

OBJECTIVE

Hemodynamic instability following emergent endotracheal intubation (EETI) is a potentially life-threatening adverse event. The objectives of this systematic literature review were to document the incidence of postintubation hemodynamic instability (PIHI), to determine the definitions for PIHI used in the available literature, and to examine factors associated with PIHI in adult patients who require EETI.

DATA SOURCE

Articles published in Medline (1966-August 2012).

STUDY SELECTION

This systematic review included adult, in-hospital studies of EETIs. Studies with nonemergent or pediatric patient populations were excluded.

DATA EXTRACTION

Two authors independently performed data abstraction. Disagreements were resolved by a third party. The methodological quality of included studies was assessed with the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies.

DATA SYNTHESIS

We estimated the pooled prevalence of PIHI across studies using a random effects meta-analysis. Subgroups analyzed included study design, intubation setting, geographic location of the study, physician experience, medications used for sedation, neuromuscular blockade, and definition of PIHI. Eighteen studies were analyzed, with sample sizes from 84 to 2,833 patients. The incidence of PIHI ranged from 5 to 440 cases per 1,000 intubations, with a pooled estimate of 110 cases per 1,000 intubations (95% CI 65-167).

CONCLUSIONS

PIHI was found to occur in 110 cases per 1,000 in-hospital, emergent intubations. However, heterogeneity among the included studies limits the reliability of this summary estimate. Further investigation is warranted.

The impact of etomidate on mortality in trauma patients

INTRODUCTION

Etomidate has a neutral hemodynamic profile which has made it an attractive medication for emergent intubation. Despite theoretical advantages of etomidate administration in the trauma patient, there are incomplete data to support its use. This study examined the association of etomidate use for emergent intubation in traumatic illness with patient mortality.

METHODS

This is a historical cohort study using the Nova Scotia Trauma Registry. It included all major adult trauma patients who required tracheal intubation at the Queen Elizabeth II Health Sciences Centre in Halifax, Canada from January 23, 2000 to March 25, 2012. Prospectively recorded data were analyzed, including patient demographics, presence of comorbidities, trauma specific variables, admission and discharge vitals, length of stay in the intensive care unit (ICU) and hospital, mechanical ventilation-free days, and mortality. Associations between the use of etomidate and 28-day mortality are presented as odds ratios. Multivariable logistic regression models were created adjusting for age, injury severity score (ISS), sex, comorbidities, presence of traumatic brain injury, and injury type. The effects of etomidate on other relevant outcome variables were assessed using unpaired Student's t-tests.

RESULTS

Three hundred eight patients were included in the study, and there were 42 deaths. Patients receiving etomidate were similar to those who did not, including ISS and pre-intubation blood pressure. The 28-day mortality was 18.7% in the etomidate group and 11.1% in the non-etomidate group (odds ratio = 1.85; 95% confidence interval [CI] 0.96 to 3.57; P = 0.07). After adjustment for age, female sex, ISS, and comorbidity, the odds ratio was 1.94 (95% CI 0.87 to 4.37; P = 0.11). There were no differences between the two groups in ICU length of stay, hospital length of stay, or number of ventilation-free days.

CONCLUSION

The association between use of a single dose of etomidate for emergency tracheal intubation in the trauma patient and mortality is inconclusive. Etomidate administration should be used with caution in trauma patients requiring tracheal intubation. Further data are required to determine the safety and risk-benefit of etomidate use in this patient population.