Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

The effect between etomidate and ketamine on peri-intubation hypotension in elderly patients in the emergency department

BACKGROUND

Peri-intubation hypotension (PIH) is associated with increased mortality. Etomidate and ketamine are commonly used as induction agents for tracheal intubation in the emergency department (ED) due to their favorable hemodynamic profiles. However, the effects of these agents on PIH remain controversial, and data on elderly patients are limited. This study aimed to compare the effects of etomidate and ketamine on PIH and 28-day mortality.

METHODS

A prospective, observational, propensity-matched cohort study was performed across two ED centers between March 23, 2022, and September 30, 2023. Patients aged 65 years and older requiring tracheal intubation and receiving either etomidate or ketamine as a single induction agent were included. The primary outcome was the incidence of PIH within 30 min post-induction, comparing etomidate and ketamine. PIH was defined as a systolic blood pressure (SBP) decrease of more than 20 % from baseline, SBP <100 mmHg (with or without fluid resuscitation), or the initiation or increased dose of vasopressor therapy. Secondary outcomes included 28-day mortality and subgroup analysis evaluating the effect of induction dose on PIH in patients with a shock index (SI) ≥0.9. Statistical analyses included a chi-square test to compare PIH incidence and Cox regression analysis to assess the association between induction agents and 28-day mortality. Multivariable Cox regression was adjusted for mortality by vasopressor initiation or escalation. Fractional polynomial regression was used to evaluate the relationship between induction agent dose and PIH.

RESULTS

A total of 418 patients were included in the analysis, with 222 patients matched in a 1:1 propensity score analysis. The incidence of PIH was 44.1 % in the etomidate group and 53.2 % in the ketamine group (risk difference 9.1 %, 95 % confidence interval [CI] -4.1 to 22.1, p = 0.179). 28-day mortality was 36.0 % in the etomidate group and 25.2 % in the ketamine group (hazard ratio [HR] 0.66, 95 % CI 0.41-1.07, p = 0.095). However, in patients who developed PIH and required vasopressors, ketamine was associated with a lower risk of 28-day mortality (adjusted HR 0.59, 95 % CI 0.36-0.97, p = 0.034). Among patients with SI ≥0.9, a higher induction agent dose was associated with an increased probability of PIH for both etomidate and ketamine.

CONCLUSION

There was no statistically significant difference in PIH and 28-day mortality between etomidate and ketamine as a single induction agent in elderly patients in the ED.

Intubation Setting and Mortality in Trauma Patients Undergoing Hemorrhage Control Surgery: A Propensity Score-Matched Analysis

BACKGROUND

Endotracheal intubation is essential for airway management in trauma patients but may cause hemodynamic instability and delay critical resuscitation measures. Recent studies have suggested that emergency department (ED) intubation may be linked with higher mortality compared to operating room (OR) intubation in trauma patients. However, it remains unclear if these findings apply to broader trauma populations, including both civilian and military patients. This study uses a nationwide trauma registry to test the hypothesis that ED intubation is associated with higher in-hospital mortality among major trauma patients, compared to OR intubation.

METHODS

Registry-based analysis of the Israeli National Trauma Registry evaluating major trauma (Injury Severity Score [ISS] ≥16) patients requiring hemorrhage control surgery between 2016 and 2023. ED intubation was the main exposure variable with in-hospital mortality serving as the primary outcome. Multivariable logistic regression and propensity score matching were applied to adjust for confounders, including injury severity, ED vital signs, penetrating injury, and blood product administration.

RESULTS

The study included 975 patients, 470 (48.2%) of whom were intubated in the ED. ED-intubated patients had significantly higher ISS and higher proportion of profound shock compared to those intubated in the OR. In-hospital mortality was more common among patients intubated in the ED (22.6%) as compared with those intubated in the OR (8.5%). In the unadjusted logistic regression, ED intubation was associated with higher odds of in-hospital mortality (OR: 3.13, 95% confidence interval [CI], 2.15-4.62). However, after adjusting for several potential confounders, the association became nonsignificant and was persistent across sensitivity subgroup analyses. Propensity score matching resulted in 1:1 matching of 271 patients in each group, balancing characteristics such as ISS, profound shock, Glasgow Coma Scale, and penetrating injury. After matching, the mortality rate was similar between groups (12.5% for ED intubation vs 12.2% for OR intubation). In the matched cohort, logistic regression demonstrated no significant association between ED intubation and in-hospital mortality (OR: 0.97, 95% CI, 0.58-1.61). ED intubation was associated with a greater than 2-fold increase in odds of ICU admission in adjusted and propensity score-matched analyses.

CONCLUSIONS

ED intubation was not significantly associated with increased in-hospital mortality after controlling for injury severity and shock. These findings suggest that while ED intubation may be more frequent in severely injured patients, its independent impact on mortality in patients undergoing emergent surgery remains unclear, warranting further prospective investigation.

Outcomes of Sedative Hypnotic Agents Used for Endotracheal Intubation in Critically Ill Adults: A Systematic Review with Exploratory Meta-Analysis

ObjectiveSpecific sedative hypnotic agents, administered to facilitate endotracheal intubation (ETI) in critically ill adults, may lead to adverse outcomes such as peri-intubation cardiovascular collapse. However, little is known from systematic investigations of the impact these individual agents have on cardiovascular function or other clinical outcomes.Data sourcesMEDLINE, Embase, CENTRAL, ClinicalTrials.gov, Scopus and Web of science databases.Study selectionWe conducted a systematic search for randomized and non-randomized studies that evaluated adult (≥18 years) critically ill patients who were sedated to facilitate ETI with ketamine, propofol, ketamine/propofol, etomidate, or a benzodiazepine and who had data on peri-intubation hemodynamics and at least one other outcome involving acute kidney injury, delirium, opioid use, intubation difficulty, sequential organ failure assessment, length of stay, or mortality. Eighty-five studies were identified for eligibility assessment with 23 included in the analysis.Data extractionTwo reviewers independently screened articles, extracted data from selected articles, and assessed risk of bias using ROBINS-I for observational studies and revised Cochrane Risk of Bias tool for randomized controlled trials.Data synthesisAcute cardiovascular dysfunction (peri-intubation hemodynamic instability and/or cardiac arrest) was similar between etomidate and ketamine with more events seen when propofol versus non-propofol sedation was administered. However, exploratory meta-analysis demonstrated no difference between etomidate and ketamine (OR 1.05 [95%CI 0.60-1.84]) or between etomidate and propofol (OR 0.91 [95%CI 0.33-2.46]). Compared to ketamine, etomidate demonstrated lower survival to hospital discharge in the included studies in exploratory meta-analysis OR 0.76 (95%CI 0.62-0.92). Limited data existed for other outcomes with no discernible differences between sedative agents.ConclusionsAcute cardiovascular dysfunction was more common when propofol, as compared to non-propofol sedation, was administered, although not statistically significant in exploratory meta-analysis. In addition, etomidate conferred lower survival to hospital discharge versus non-etomidate sedation, which was confirmed in exploratory meta-analysis of etomidate versus ketamine.

Prehospital paediatric trauma: equipping prehospital providers to deliver high-quality care

INTRODUCTION

Trauma is the leading cause of death in children over 1 year of age in the UK. However, individual prehospital clinicians only encounter paediatric trauma patients rarely. This study describes the frequency and type of paediatric trauma experienced by a mature prehospital trauma service in an urban environment to inform prehospital services about the type of injuries likely to be attended, and the key interventions that might be required on scene.

STUDY DESIGN

Retrospective review of patients 16 years of age and under attended by a physician-led prehospital trauma service between January 2017 and June 2022. Patients were divided into subgroups of 0-4 years, 5-11 years and 12-16 years.

RESULTS

782 paediatric patients were included, which comprised 8.3% of total patient workload. The median age was 15 years old (IQR 5-16 years) and the majority were male (n=597, 76.3%). The most common mechanism of injury for subgroups were falls from height (>2 m) in 0-4 year olds, road traffic collisions in 5-11 year olds and penetrating trauma in 12-16 year olds. 20.2% (n=158) of patients attended received critical care interventions. 9.8% (n=77) underwent prehospital emergency anaesthesia (PHEA) and 7.4% (n=58) received a blood transfusion.

CONCLUSION

Paediatric major trauma constitutes only a small minority of prehospital care workload. However, cases are attended regularly. Attending prehospital teams need to be trained to perform difficult resuscitations and perform high acuity, low frequency interventions. Educational and training strategies required to equip prehospital providers treating paediatrics may include checklists, algorithms, simulation training and mental health support.

Post-induction hypotension during rapid sequence intubation in the operating room: A post hoc analysis of the randomized controlled REMICRUSH trial

BACKGROUND

We explored the risk factors of post-induction hypotension during rapid sequence intubation.

METHODS

We performed an ancillary analysis of a multicenter randomized clinical trial comparing remifentanil versus neuromuscular blockers associated with hypnotic in patients at risk for aspiration who underwent tracheal intubation in the operating room. The primary outcome was post-induction hypotension, defined as an episode of hypotension (MBP ≤ 55 mmHg and/or SBP ≤ 80 mmHg) within 10 min after anesthetic induction.

RESULTS

From 15 hospitals, 1137 adult patients were included, and 291 (26%) had post-induction hypotension. Propofol was used in 1117 (98%) patients and was associated with low doses of ketamine in 209 (18 %) patients. The independent risk factors associated with post-induction hypotension were age (OR 1.03, 95% CI [1.02; 1.04] p < 0.0001), baseline heart rate (p = 0.0068), bowel occlusion requiring nasogastric tube placement before intubation (OR 1.96, 95% CI [1.33; 2.87] p = 0.0006) and use of remifentanil (OR 3.54, 95%CI (2.61; 4.81) p < 0.0001). Use of low doses of ketamine (OR 0.61, 95% CI [0.41; 0.92] p = 0.0175) and basal SBP (OR 0.98, 95% CI [0.97; 0.99] p < 0.0001) were protective factors. The precision of the final model including the above-mentioned variables gave an AUC of 0.74 [95% CI 0.71; 0.77] for post-induction hypotension prediction.

CONCLUSIONS

Post-induction hypotension was frequent during rapid sequence intubation. Sedation associating propofol with low doses of ketamine was associated with a low risk of post-induction hypotension. Further studies are required to demonstrate a causal effect.

REGISTRATION

ClinicalTrials.gov NCT03960801.

Optimizing Sedation Strategies in the Cardiac ICU: Induction, Maintenance and Weaning

PURPOSE OF REVIEW

We aim to summarize the available literature guiding tailored sedation practices for specific conditions encountered in the Cardiovascular Intensive Care Unit (CICU).

RECENT FINDINGS

Data specific for the CICU population is lacking. Preclinical data and observational studies guide sedation approaches for specific pathologies that we have used to generate a guideline for sedative choice for various scenarios. We discuss the challenges associated with extubation and highlight the importance of spontaneous breathing trials and role of non invasive ventilation. Understanding the underlying pathology and the effects of sedation and positive pressure ventilation is the base to guide induction and sedation management for patients in the CICU. There is a pressing need for further research to generate high quality clinical data to improve sedation techniques in the CICU.

Postintubation hypotension following rapid sequence intubation with full- vs reduced-dose induction agent

PURPOSE

Rapid sequence intubation (RSI) is a common emergency department (ED) procedure with an associated complication of postintubation hypotension (PIH). It has not been clearly established whether the selection and dose of induction agent affect risk of PIH. The objective of this study was to determine the incidence of PIH in patients receiving full-dose compared to reduced-dose induction agent for RSI in the ED.

METHODS

This was a health system-wide, retrospective cohort study comparing incidence of PIH based on the induction medication and dose given for RSI in the ED. Patients were included if they underwent RSI from July 1, 2018, through December 31, 2020, were 18 years of age or older, and received etomidate or ketamine. A reduced dose was defined as a ketamine dose of 1.25 mg/kg or less and an etomidate dose of 0.2 mg/kg or less.

RESULTS

A total of 909 patients were included in the final analysis, with most receiving etomidate (n = 764; 84%) and a smaller number receiving ketamine (n = 145; 16%). Patients who received ketamine had a higher mean pre-intubation shock index (full dose, 1.08; reduced dose, 1.04) than those who received etomidate (full dose, 0.89; reduced dose, 0.92) (P ≤ 0.001). Reduced doses of induction agent were observed for 107 patients receiving etomidate (14.0%) and 60 patients receiving ketamine (41.4%). Patients who received full-dose ketamine for induction had the highest rate of PIH (n = 31; 36.5%), and the difference was statistically significant compared to patients receiving reduced-dose ketamine (16.7%; P = 0.021) and full-dose etomidate (22.8%; P = 0.010).

CONCLUSION

We observed that full-dose ketamine was associated with the highest rate of PIH; however, this group had the poorest baseline hemodynamics, confounding interpretation. Our results do not support broad use of a reduced-dose induction agent.

The Importance of Circulation in Airway Management: Preventing Postintubation Hypotension in the Trauma Bay

OBJECTIVE

To identify the modifiable and nonmodifiable risk factors associated with postintubation hypotension (PIH) among trauma patients who required endotracheal intubation (ETI) in the trauma bay.

BACKGROUND

ETI has been associated with hemodynamic instability, termed PIH, yet its risk factors in trauma patients remain underinvestigated.

METHODS

This is a prospective observational study at a level I trauma center over 4 years (2019-2022). All adult (≥18) trauma patients requiring ETI in the trauma bay were included. Blood pressure was monitored both preintubation and postintubation. Multivariable logistic regression analysis was performed to identify the modifiable and nonmodifiable factors associated with PIH.

RESULTS

Seven hundred eight patients required ETI in the trauma bay, of which, 435 (61.4%) developed PIH. The mean (SD) age was 43 (21) years and 71% were male. Median [interquartile range] arrival Glasgow Coma Scale was 7 [3-13]. Patients who developed PIH had a lower mean (SD) preintubation systolic blood pressure [118 (46) vs 138 (28), P <0.001] and higher median [interquartile range] Injury Severity Score: 27 [21-38] versus 21 [9-26], P <0.001. Multivariable regression analysis identified body mass index >25, increasing Injury Severity Score, penetrating injury, spinal cord injury, preintubation packed red blood cell requirements, and diabetes mellitus as nonmodifiable risk factors associated with increased odds of PIH. In contrast, preintubation administration of 3% hypertonic saline and vasopressors were identified as the modifiable factors significantly associated with reduced PIH.

CONCLUSIONS

More than half of the patients requiring ETI in the trauma bay developed PIH. This study identified modifiable and nonmodifiable risk factors that influence the development of PIH, which will help physicians when considering ETI upon patient arrival.

LEVEL OF EVIDENCE

Level III-Prognostic study.

Intubation of critically ill patients: A pilot study of minute-by-minute physiological changes within an Australian tertiary intensive care unit

BACKGROUND

There are no published minute-by-minute physiological assessment data for endotracheal intubation (ETT) performed in the intensive care unit (ICU). The majority of physiological data is available from Europe and North America where etomidate is the induction agent administered most commonly.

AIMS

The aim of this study was to describe the feasibility of obtaining minute-by-minute physiological and medication data surrounding ETT in an Australian tertiary ICU and to assess its associated outcomes.

METHODS

We performed a single-centre feasibility observational study. We obtained minute-by-minute data on physiological variables and medications for 15 min before and 30 min after ETT. We assessed feasibility as enrolled to screened patient ratio and completeness of data collection in enrolled patients. Severe hypotension (systolic blood pressure < 65 mmHg) and severe hypoxaemia (pulse oximetry saturation < 80%) were the secondary clinical outcomes.

RESULTS

We screened 43 patients and studied 30 patients. The median age was 58.5 (interquartile range: 49-70) years, and 18 (60%) were male. Near-complete (97%) physiological and medication data were obtained in all patients at all times. Overall, 15 (50%) ETTs occurred after hours (17:30-08:00) and 90% were by video laryngoscopy with a 90% first-pass success rate. Prophylactic vasopressors were used in 50% of ETTs. Fentanyl was used in all except one ETT at a median dose of 2.5 mcg/kg. Propofol (63%) or midazolam (50%) were used as adjuncts at low dose. Rocuronium was used in all but one patient. There were no episodes of severe hypotension and only one episode of short-lived severe hypoxaemia.

CONCLUSION

Minute-by-minute recording of ETT-associated physiological changes in the ICU was feasible but only fully available in two-thirds of the screened patients. ETT was based on fentanyl induction, low-dose adjunctive sedation, and frequent prophylactic vasopressor therapy and was associated with no severe hypotension and a single short-lived episode of severe hypoxaemia.

A Systematic Review and Meta-Analysis of Prophylactic Vasopressors for the Prevention of Peri-Intubation Hypotension

BACKGROUND/OBJECTIVES

Peri-intubation hypotension is a known complication of endotracheal intubation. In the hospital setting, peri-intubation hypotension has been shown to increase hospital mortality and length of stay. The use of prophylactic vasopressors at the time of sedation induction to prevent peri-intubation hypotension has been raised. This systematic review and meta-analysis aims to review the safety and efficacy of this practice.

METHODS

The study was fully registered with PROSPERO on 13 October 2022, and screening for eligibility was initiated on 20 September 2024. Randomized controlled trials, along with retrospective or prospective cohort studies, were included in the search. The terms "peri-intubation hypotension", "vasopressors", "intubation", and "anesthesia induced hypotension" were used to search the title/summary in PubMed, Cochrane Library, and Google Scholar databases. An assessment of bias for each study was conducted using the Newcastle-Ottawa Quality Assessment Scale. The primary outcome was the rate of hypotension peri-intubation. Any complications secondary to hypotension or vasopressors were the secondary outcome.

RESULTS

We identified 13 studies, which were all randomized controlled studies, to include in the final analysis. The risk ratio for preventing peri-intubation hypotension was 1.6 (95% CI, 1.2-2.14) with the use of prophylactic phenylephrine while giving propofol versus no prophylactic vasopressors and 1.28 (95% CI 1.03-1.60) with the use of ephedrine.

CONCLUSIONS

These findings suggest that in patients undergoing intubation in the operating room with propofol, prophylactic vasopressors given with induction for intubation decrease the odds of hypotension.

Association between metabolic acidosis and post-intubation hypotension in airway management performed in the emergency department

Introduction

Post-intubation hypotension (PIH) is a common complication of intubations performed in the emergency department (ED). Identification of patients at high-risk for PIH is a major challenge. We aimed to determine whether pre-intubation metabolic acidosis affects the incidence of PIH in the ED.

Methods

This was a single-center, retrospective, observational study of consecutive patients requiring emergent endotracheal intubation (ETI) from November 1, 2016 to March 31, 2022 at Hyogo Emergency Medical Center, an urban ED. The primary outcome was PIH, defined as a decreased systolic blood pressure (sBP) of <90 mmHg, required initiation of any vasopressor, or a decrease in sBP by ≥ 20 % within 30 min following intubation. Patients were divided into two groups: those with pre-intubation metabolic acidosis (metabolic acidosis group), defined as pH < 7.3 and base excess (BE) < -4 mmol/L on arterial blood gas analysis, and those with no metabolic acidosis (without-metabolic acidosis group). The association between PIH and pre-intubation metabolic acidosis was examined using multivariable logistic regression models. A receiver operating characteristic (ROC) curve was produced to assess the predictive value of pre-intubation BE for PIH.

Results

The study included 311 patients. PIH occurred in 65.5 % (74/113) of patients in the metabolic acidosis group and 29.3 % (58/198) of patients in the without-metabolic acidosis group. Multivariable logistic regression demonstrated that metabolic acidosis was associated with PIH (odds ratio 4.06, 95 % confidence interval 2.31-7.11). In the ROC analysis, the optimal cut-off point for BE was -4.1 (sensitivity = 71 %, specificity = 70 %), with the area under the ROC curve 0.74.

Conclusion

Pre-intubation metabolic acidosis was significantly associated with PIH. Physicians.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

PURPOSE

Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA).

METHODS

An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS

The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care.

CONCLUSION

Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Association of Shock Indices with Peri-Intubation Hypotension and Other Outcomes: A Sub-Study of the KEEP PACE Trial

BACKGROUND

Based on current evidence, there appears to be an association between peri-intubation hypotension and patient morbidity and mortality. Studies have identified shock indices as possible pre-intubation risk factors for peri-intubation hypotension. Thus, we sought to evaluate the association between shock index (SI), modified shock index (MSI), and diastolic shock index (DSI) and peri-intubation hypotension along with other outcomes.

METHODS

The present study is a sub-study of a randomized controlled trial involving critically ill patients undergoing intubation. We defined peri-intubation hypotension as a decrease in mean arterial pressure <65 mm Hg and/or a reduction of 40% from baseline; or the initiation of, or increase in infusion dosage of, any vasopressor medication (bolus or infusion) during the 30-min period following intubation. SI, MSI, and DSI were analyzed as continuous variables and categorically using pre-established cut-offs. We also explored the effect of age on shock indices.

RESULTS

A total of 151 patients were included in the analysis. Mean pre-intubation SI was 1.0  ±  0.3, MSI 1.5  ±  0.5, and DSI 1.9  ±  0.7. Increasing SI, MSI, and DSI were significantly associated with peri-intubation hypotension (OR [95% CI] per 0.1 increase  =  1.16 [1.04, 1.30], P  =  .009 for SI; 1.14 [1.05, 1.24], P  =  .003 for MSI; and 1.11 [1.04, 1.19], P  =  .003 for DSI). The area under the ROC curves did not differ across shock indices (0.66 vs 0.67 vs 0.69 for SI, MSI, and DSI respectively; P  =  .586). Increasing SI, MSI, and DSI were significantly associated with worse sequential organ failure assessment (SOFA) score (spearman rank correlation: r  =  0.30, r  =  0.40, and r  =  0.45 for SI, MSI, and DSI, respectively, all P < .001) but not with other outcomes. There was no significant impact when incorporating age.

CONCLUSIONS

Increasing SI, MSI, and DSI were all significantly associated with peri-intubation hypotension and worse SOFA scores but not with other outcomes. Shock indices remain a useful bedside tool to assess the potential likelihood of peri-intubation hypotension.

TRIAL REGISTRATION

ClinicalTrials.gov identifier - NCT02105415.

Impact of resuscitation adjuncts on postintubation hypotension in patients with isolated traumatic brain injury

INTRODUCTION

Postintubation hypotension (PIH) is a risk factor of endotracheal intubation (ETI) after injury. For those with traumatic brain injury (TBI), one episode of hypotension can potentiate that injury. This study aimed to identify the resuscitation adjuncts that may decrease the incidence of PIH in this patient population.

METHODS

This is a 4-year (2019-2022) prospective observational study at a level I trauma center. Adult (18 years or older) patients with isolated TBI requiring ETI in the trauma bay were included. Blood pressures were measured 15 minutes preintubation and postintubation. Primary outcome was PIH, defined as a decrease in systolic blood pressure of ≥20% from baseline or to ≤80 mm Hg, or any decrease in mean arterial pressure to ≤60 mm Hg. Multivariable logistic regression was performed to identify the associations of preintubation vasopressor, hypertonic saline (HTS), packed red blood cell, and crystalloids on PIH incidence.

RESULTS

Of the 490 enrolled patients, 16% had mild (head AIS, ≤2), 35% had moderate (head AIS, 3-4), and 49% had severe TBI (head AIS, ≥5). The mean ± SD age was 42 ± 22 years, and 71% were male. The median ISS, head AIS, and Glasgow Coma Scale were 26 (19-38), 4 (3-5), and 6 (3-11), respectively. The mean ± SD systolic blood pressure 15 minutes preintubation and postintubation were 118 ± 46 and 106 ± 45, respectively. Before intubation, 31% received HTS; 10%, vasopressors; 20%, crystalloids; and 14%, at least 1 U of packed red blood cell (median, 2 [1-2] U). Overall, 304 patients (62%) developed PIH. On multivariable regression analysis, preintubation use of vasopressors and HTS was associated with significantly decreased odds of PIH independent of TBI severity, 0.310 (0.102-0.944, p = 0.039) and 0.393 (0.219-0.70, p = 0.002), respectively.

CONCLUSION

Nearly two thirds of isolated TBI patients developed PIH. Preintubation vasopressors and HTS are associated with a decreased incidence of PIH. Such adjuncts should be considered prior to ETI in patients with suspected TBI.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

OBJECTIVE

To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED.

METHODS

A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs).

RESULTS

Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8).

CONCLUSIONS

Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

A Prospective Study Evaluating Gender Differences of Serious Outcomes through Difficult Airway Physiological Score (DAPS) in the Emergency Department

Introduction

Gender variation in critically ill adults after resuscitation is reported in many studies. However, this variation is not well established when evaluating the physiological instability in this population. This study aimed to prospectively evaluate the gender variation in serious outcomes by the difficult airway physiological score (DAPS) among critically ill patients requiring endotracheal intubation (ETI).

Methods

This is a cohort study conducted from August 2021 to December 2022 in the emergency department of Aga Khan University. The prospective validity of the difficult airway physiological score was derived using retrospective data and includes 12 variables: sex, age, time of intubation, hypotension, respiratory distress, vomiting, shock index >0.9, pH < 7.3, fever, anticipated decline, Glasgow Coma Scale (GCS) < 15, and agitation. The serious outcomes were cardiac arrest, mortality (within 1 hour after intubation in emergency), hypotension (systolic blood pressure <90 mmHg), and oxygen desaturation (SpO2 < 92%). The difference between males and females was assessed using the chi-square test, and the association of gender and serious outcomes was explored using Cox and logistic regression analysis. ROC curve analysis and area under the curve assessed score validity separately in males and females with serious outcomes.

Results

We enrolled 326 patients with a mean age of 50.3 (±17.8), with 123 (33.7%) females and 203 (62.2%) males. 198 (60.7%) patients were >45 years old, of which 136 (67%) were male and 62 (50.4%) female. Cardiac arrest was observed in 56 (17.2%), with 24 (19.5%) females and 32 (15.8%) males, p value 0.348. Hypotension after intubation was observed in 132 (40.5%) patients, 56 (45.5%) females and 76 (37.4%) males, p value 0.149. Oxygen saturation (<92%) was observed in 80 (24.5%) patients, 32 (26%) females and 48 (23.6%) males, p value 0.630. In females, the DAPS of 11 had an area under the curve of 0.863 (0.74-0.91). The sensitivity of the score was 84.8%, the specificity was 71.9%, the PPV was 77.8%, and the NPV was 80.4% with an accuracy of 78.9%. In males, the DAPS score of 14 had an area under the curve of 0.892 (0.57-0.75). The sensitivity of the score was 67%, the specificity 93.8%, the PPV 92.2%, and the NPV 72.2% with an accuracy of 79.8%.

Conclusions

The Difficult Airway Physiological Score (DAPS) predicts the risk of serious outcomes after intubation with high precision and reliability with different score cutoffs between the two sexes, highlighting the gender variation of a difficult airway.

Noninvasive Cardiac Output Monitoring (NICOM) in the Critically Ill Patient Undergoing Endotracheal Intubation: A Prospective Observational Study

Background: Cardiovascular instability occurring during endotracheal intubation (ETI) in the critically ill is a commonly recognized phenomenon. However, this complication has not been evaluated in terms of the physiological cause (ie, decreased preload, contractility, or afterload) leading to the instability. Thus, the aim of the current investigation was to describe the hemodynamics occurring during ETI with noninvasive physiologic monitoring and to collect preliminary data on the hemodynamic effects of induction agents and positive pressure ventilation. Methods: A multicenter prospective study enrolling adult (≥18 years) critically ill patients undergoing ETI with noninvasive cardiac output monitoring in a medical/surgical intensive care unit from June 2018 to May 2019 was conducted. This study used the Cheetah Medical noninvasive cardiac output monitor to collect hemodynamic data during the peri-intubation period. Additional data collected included baseline characteristics such as illness severity, peri-intubation pharmacologic administration, and mechanical ventilation settings. Results: From the original 27 patients, only 19 (70%) patients had complete data and were included in the final analysis. Propofol was the most common sedative 8 (42%) followed by ketamine 6 (32%) and etomidate 5 (26%). Patients given propofol demonstrated a decrease in total peripheral resistance index (delta change [dynes × s/cm-5/m2]: -2.7 ± 778.2) but stabilization in cardiac index (delta change (L/min/m2]: 0.1 ± 1.5) while etomidate and ketamine demonstrated increases in total peripheral resistance index (etomidate delta change [dynes × s/cm-5/m2]: 302.1 ± 414.3; ketamine delta change [dynes × s/cm-5/m2]: 278.7 ± 418.9) but only etomidate resulted in a decrease in cardiac index (delta change [L/min/m2]: -0.3 ± 0.5). Positive pressure ventilation resulted in minimal changes to hemodynamics during ETI. Conclusions: The current study demonstrates that although propofol administration leads to a decrease in total peripheral resistance index, cardiac index is maintained while etomidate leads to a decrease in cardiac index with both etomidate and ketamine increasing total peripheral resistance index. These hemodynamic profiles are minimally affected by positive pressure ventilation. Study registration: ClinicalTrials.gov ID, NCT03525743.

A Nomogram Model for Post-Intubation Hypotension in Patients with Severe Pneumonia in the Emergency Department

Background

Post-intubation hypotension (PIH) frequently occurs in the management of critically ill patients and is associated with prognosis. The study aimed to construct a prediction model for PIH events by analyzing risk factors in patients with severe pneumonia in the emergency department.

Methods

We retrospectively enrolled 572 patients with severe pneumonia diagnosed in the emergency department of West China Hospital of Sichuan University. Five hundred patients with severe pneumonia who underwent endotracheal intubation were included in the study. All patients were randomized according to 7:3 and divided into a training cohort (n=351) and a validation cohort (n=149). Risk factors for PIH were analyzed using Least Absolute Shrinkage and Selection Operator (LASSO) and multivariable logistic regression. Calibration curves, receiver operating characteristic (ROC) curve, and decision curve analysis were applied to assess the predictive model's fitness, discrimination, and clinical utility.

Results

A total of 500 patients with severe pneumonia who underwent endotracheal intubation were enrolled in this study, and PIH occurred in 234 (46.8%) of these patients. Age, heart rate, systolic blood pressure, chronic obstructive pulmonary disease, acute physiology and chronic health evaluation II score, and induction agent use were identified as significant risk factors for the occurrence of PIH. Additionally, the body mass index was the opposite of the above. The area under the ROC curve (AUC) for the model was 0.856 (95% CI, 0.818-0.894) in the training cohort and 0.849 (95% CI, 0.788-0.910) in the validation cohort. The nomogram model was validated and demonstrated good calibration and high net clinical benefit. Finally, to facilitate application by clinicians, an online server has been set up which can be accessed free of charge via the website https://chinahospitals.shinyapps.io/DynNomapp/.

Conclusion

The nomogram is used for individualized prediction of patients with severe pneumonia prior to intubation and is simple to perform with high clinical value.

Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials

PURPOSE

We performed a meta-analysis of randomized controlled trials to evaluate if etomidate impacted mortality in critically ill adults when compared with other induction agents.

MATERIALS AND METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for randomized controlled trials which compared etomidate with any other induction agent in critically ill adult patients undergoing endotracheal intubation. The primary outcome was mortality at the main timepoint defined by the study. We conducted a fixed-effects meta-analysis for the risk ratio. Using that risk ratio and 95% confidence interval, we then estimated the probability of any harm (RR > 1) and the number needed to harm ≤100 (RR ≥ 1.05).

RESULTS

We included 11 randomized trials comprising 2704 patients. We found that etomidate increased mortality (319/1359 [23%] vs. 267/1345 [20%]; risk ratio (RR) = 1.16; 95% confidence interval (CI), 1.01-1.33; P = 0.03; I2 = 0%; number needed to harm = 31). The probabilities of any increase and a 1% increase (NNH ≤100) in mortality were 98.1% and 92.1%, respectively.

CONCLUSIONS

This meta-analysis found a high probability that etomidate increases mortality when used as an induction agent in critically ill patients with a number needed to harm of 31.

Effects of Etomidate on Postintubation Hypotension, Inflammatory Markers, and Mortality in Critically Ill Patients with COVID-19: An International, Multicenter, Retrospective Study

OBJECTIVE

To evaluate the association of etomidate with postintubation hypotension, inflammation, and mortality in critically ill patients with COVID-19.

DESIGN

International, multicenter, retrospective study.

PARTICIPANTS

Critically ill patients hospitalized specifically for COVID-19 from three major academic institutions in the US and Europe.

MAIN OUTCOME AND MEASURES

Patients were allocated into the etomidate (ET) group or another induction agent (OA) group. The primary outcome was postintubation hypotension. Secondary outcomes included postintubation inflammatory status, in-hospital mortality, and mortality at 30 days.

RESULTS

171 patients with a median age of 68 (IQR 58-73) years were included (ET, n  =  98; OA, n  =  73). Etomidate was associated with lower postintubation mean arterial pressure [74.33 (64-85) mm Hg versus 81.84 (69.75-94.25) mm Hg, p  =  0.005] compared to other agents. No statistically significant differences were generally observed in inflammatory markers between the two groups at 7- and 14-days after admission to the intensive care unit. In-hospital mortality [77 (79%) versus 41 (56%), p  =  0.003] and mortality at 30-days [78 (80%) versus 43 (59%), p  =  0.006] were higher in the ET group. In multivariate logistic regression analysis, only etomidate (p  =  0.009) and postintubation mean arterial pressure (p < 0.001) had a statistically significant effect on mortality, in contrast to stress-dose steroids (p  =  0.301), after adjusting for creatinine (p  =  0.695), blood urea nitrogen (p  =  0.153), age (p  =  0.055), oxygen saturation of hemoglobin (SpO2) (p  =  0.941), and fraction of inspired oxygen (FiO2) (p  =  0.712).

CONCLUSIONS

Administration of a single-bolus dose of etomidate in critically ill patients with COVID-19 is associated with lower postintubation mean arterial pressure and higher in-hospital and 30-day mortality compared to other induction agents.

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes.

DESIGN

A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors.

SETTING

Seven emergency departments and 17 ICUs across the United States.

PATIENTS

One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (-12 vs -11 mm Hg; p = 0.66).

CONCLUSIONS

The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.

Dexmedetomidine vs. Fentanyl-Midazolam Combination to Mitigate the Stress Response in Microlaryngoscopy: A Randomized Double-blind Clinical Trial

Background

Laryngoscopy is the most painful noxious stimulus during anesthesia and surgery. Dexmedetomidine is increasingly used as a sedative in surgeries involving microlaryngoscopy.

Objectives

This study aimed to evaluate the effect of dexmedetomidine and a combination of fentanyl and midazolam on mitigating the stress response in patients scheduled for microlaryngoscopy.

Methods

This randomized, double-blind clinical trial enrolled 60 patients (28 males and 32 females) aged 18 - 65 years with the American Society of Anesthesiologists (ASA) physical status I - III. The patients were scheduled for microlaryngoscopy and equally divided into 2 groups. Group D received 1 μg/kg of dexmedetomidine and saline bolus dose over 10 minutes before general anesthesia (GA) induction, followed by 0.5 μg/kg/h of dexmedetomidine and saline infusions after GA induction. Group MF received 0.8 μg/kg of fentanyl plus 0.05 mg/kg of midazolam over 10 minutes before GA induction, followed by 1 μg/kg/h of fentanyl plus 0.05 mg/kg/h of midazolam as an infusion. The heart rate (HR) and mean arterial blood pressure (MAP) pressure were recorded from baseline until the end of surgery. Infusions were stopped at the end of the surgery.

Results

The number of patients requiring propofol and intraoperative supplemental propofol was significantly lower in group D than in group MF. The heart rate was significantly lower in group D than in group MF (P = 0.022, 0.048, 0.032, 0.045, 0.041, 0.026, 0.030, and 0.036) from induction until the end of surgery; in addition, it was comparable between both groups at baseline and before induction. MAP was comparable between both groups for all measurements.

Conclusions

Dexmedetomidine mitigates the hemodynamic changes related to microlaryngoscopy more effectively than the fentanyl-midazolam combination.

Clinical outcomes after a single induction dose of etomidate versus ketamine for emergency department sepsis intubation: a randomized controlled trial

Patients with sepsis often require emergency intubation. In emergency departments (EDs), rapid-sequence intubation with a single-dose induction agent is standard practice, but the best choice of induction agent in sepsis remains controversial. We conducted a randomized, controlled, single-blind trial in the ED. We included septic patients who were aged at least 18 years and required sedation for emergency intubation. Patients were randomly assigned by a blocked randomization to receive 0.2-0.3 mg/kg of etomidate or 1-2 mg/kg of ketamine for intubation. The objectives were to compare the survival outcomes and adverse events after intubation between etomidate and ketamine. Two hundred and sixty septic patients were enrolled; 130 patients/drug arm whose baseline characteristics were well balanced at baseline. In the etomidate group, 105 patients (80.8%) were alive at 28 days, compared with 95 patients (73.1%) in the ketamine group (risk difference [RD], 7.7%; 95% confidence interval [CI], - 2.5 to 17.9%; P = 0.092). There was no significant difference in the proportion of patients who survived at 24 h (91.5% vs. 96.2%; P = 0.097) and survived at 7 days (87.7% vs. 87.7%; P = 0.574). A significantly higher proportion of the etomidate group needed a vasopressor within 24 h after intubation: 43.9% vs. 17.7%, RD, 26.2% (95% CI, 15.4 to 36.9%; P < 0.001). In conclusion, there were no differences in early and late survival rates between etomidate and ketamine. However, etomidate was associated with higher risks of early vasopressor use after intubation. Trial registration: The trial protocol was registered in the Thai Clinical Trials Registry (identification number: TCTR20210213001). Registered 13 February 2021-Retrospectively registered, https://www.thaiclinicaltrials.org/export/pdf/TCTR20210213001 .

Bolus Vasopressor Use for Air Medical Rapid Sequence Intubation: The Vasopressor Intravenous Push to Enhance Resuscitation Trial

BACKGROUND

Rapid sequence intubation (RSI) may compromise perfusion because of the use of sympatholytic medications as well as subsequent positive pressure ventilation. The use of bolus vasopressor agents may reverse hypotension and prevent arrest.

METHODS

This was a prospective, observational study enrolling air medical patients with critical peri-RSI hypotension (systolic blood pressure [SBP] < 90 mm Hg) to receive either arginine vasopressin (aVP), 2 U intravenously every 5 minutes, for trauma patients or phenylephrine (PE), 200 μg intravenously every 5 minutes, for nontrauma patients. The main outcome measures included an increase in SBP, a reversal of hypotension, and the occurrence of dysrhythmia or hypertension (SBP > 160 mm Hg) within 20 minutes of vasopressor administration.

RESULTS

A total of 523 patients (344 aVP and 179 PE) were enrolled over 2 years. An increase in SBP was observed in 326 aVP patients (95%), with reversal of hypotension in 272 patients (79%). An increase in SBP was observed in 171 PE patients (96%), with reversal of hypotension in 148 patients (83%). A low rate of rebound hypertension was observed for both aVP and PE patients.

CONCLUSION

Both aVP and PE appear to be safe and effective for treating critical hypotension in the peri-RSI period.

Hypotension Prediction Score for Endotracheal Intubation in Critically Ill Patients: A Post Hoc Analysis of the HEMAIR Study

BACKGROUND

Hypotension with endotracheal intubation (ETI) is common and associated with adverse outcomes. We sought to evaluate whether a previously described hypotension prediction score (HYPS) for ETI is associated with worse patient outcomes and/or clinical conditions.

METHODS

This study is a post hoc analysis of a prospective observational multicenter study involving adult (age ≥18 years) intensive care unit (ICU) patients undergoing ETI in which the HYPS was derived and validated on the entire cohort and a stable subset (ie, patients in stable condition). We evaluated the association between increasing HYPSs in both subsets and several patient-centered outcomes and clinical conditions.

RESULTS

Complete data for HYPS calculations were available for 783 of 934 patients (84%). Logistic regression analysis showed increasing odds ratios (ORs) for the highest risk category for new-onset acute kidney injury (OR, 7.37; 95% CI, 2.58-21.08); new dialysis need (OR, 8.13; 95% CI, 1.74-37.91); ICU mortality (OR, 16.39; 95% CI, 5.99-44.87); and hospital mortality (OR, 18.65; 95% CI, 6.81-51.11). Although not increasing progressively, the OR for the highest risk group was significantly associated with new-onset hypovolemic shock (OR, 6.06; 95% CI, 1.47-25.00). With increasing HYPSs, median values (interquartile ranges) decreased progressively (lowest risk vs. highest risk) for ventilator-free days (23 [18-26] vs. 1 [0-21], P < .001) and ICU-free days (20 [11-24] vs. 0 [0-13], P < .001). Of the 729 patients in the stable subset, 598 (82%) had complete data for HYPS calculations. Logistic regression analysis showed significantly increasing ORs for the highest risk category for new-onset hypovolemic shock (OR, 7.41; 95% CI, 2.06-26.62); ICU mortality (OR, 5.08; 95% CI, 1.87-13.85); and hospital mortality (OR, 7.08; 95% CI, 2.63-19.07).

CONCLUSIONS

As the risk for peri-intubation hypotension increases, according to a validated hypotension prediction tool, so does the risk for adverse clinical events and certain clinical conditions.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov (NCT02508948).

Clinical investigation of a unique type of hypothalamic adrenal insufficiency

Hypothalamic adrenal insufficiency (AI) is a rare but distinct type of AI. The leading cause of hypothalamic AI is a secondary side-effect of exogenous steroid intake, particularly in large amounts and/or long-term periods. The next cause would be the effect of the tumor in the hypothalamic lesions. We show here 9 cases of hypothalamic AI without any disorder on imagings and a history of steroid administration. All patients had general fatigue; 7 patients (77.8%) had a history of hypoglycemia; 5 patients (55.6%) had a history of hypotension. None of the patients had hyponatremia, hyperkalemia, or eosinophilia. Their morning plasma adrenocorticotropic hormone (ACTH) value was low at 8.5 ± 4.2 pg/mL, and serum cortisol value was low at 4.5 ± 1.3 µg/dL. All patients demonstrated normal responses during the corticotropin-releasing hormone loading (CRH) test but inadequate responses during the insulin tolerance test (ITT). After hydrocortisone replacement therapy, their morning plasma ACTH and serum cortisol values were significantly recovered (P < .05). Moreover, more than half of the patients were fine after discontinuing hydrocortisone replacement therapy. These results indicate that this unique type of hypothalamic AI has a curable clinical course making hydrocortisone replacement therapy a novel therapeutic option.

The impact of post-intubation hypotension on length of stay and mortality in adult and geriatric patients: a cohort study

OBJECTIVE

To evaluate the association between standard post-intubation hypotension (< 90 mmHg) and in-hospital mortality. Secondary objectives were to evaluate the association of post-intubation hypotension and length of stay and to assess the impact of increasing post-intubation hypotension threshold to 110 mmHg on hospital length of stay and 48 h-mortality in patients aged ≥ 65 years.

METHODS

Design and setting: A cohort of patients admitted in a level-1 trauma centre emergency department (ED) between November 2011 and July 2016.

INCLUSION CRITERIA

aged ≥ 16 with available pre-intubation vital signs, intubation performed in ≤ 3 attempts with no surgical access needed.

MEASURES

Prospective electronic data collection was used for clinical data.

MAIN OUTCOME

48-h in-hospital mortality.

SECONDARY OUTCOME

hospital length of stay.

ANALYSES

Univariate and multivariate analyses.

RESULTS

A total of 586 patients were included. The mean age was 56.3 ± 18.8 years and 37% were aged ≥ 65 years. Within 60 min of intubation, 224 (38%) patients had at least one systolic blood pressure measure < 90 mmHg and 164(28%) had at least two measures. The < 110 mmHg threshold showed a total of 377 patients (64%) had at least one systolic blood pressure measure < 110 mmHg and 286 (49%) had at least two measures. We found no significant difference in the risk of mortality overall and in stratified-age groups and no association with increased hospital length of stay using both post-intubation hypotension thresholds.

CONCLUSION

Post-intubation hypotension was recorded in one out of three patients in the ED but we found no association between post-intubation hypotension and 48-h in-hospital mortality overall in adults or geriatric patients.

Tracheal intubation in the critically ill patient

Tracheal intubation is among the most commonly performed and high-risk procedures in critical care. Indeed, 45% of patients undergoing intubation experience at least one major peri-intubation adverse event, with cardiovascular instability being the most common event reported in 43%, followed by severe hypoxemia in 9% and cardiac arrest in 3% of cases. These peri-intubation adverse events may expose patients to a higher risk of 28-day mortality, and they are more frequently observed with an increasing number of attempts to secure the airway. The higher risk of peri-intubation complications in critically ill patients, compared with the anaesthesia setting, is the consequence of their deranged physiology (e.g. underlying respiratory failure, shock and/or acidosis) and, in this regard, airway management in critical care has been defined as "physiologically difficult". In recent years, several randomised studies have investigated the most effective preoxy-genation strategies, and evidence for the use of positive pressure ventilation in moderate-to-severe hypoxemic patients is established. On the other hand, evidence on interventions to mitigate haemodynamic collapse after intubation has been elusive. Airway management in COVID-19 patients is even more challenging because of the additional risk of infection for healthcare workers, which has influenced clinical choices in this patient group. The aim of this review is to provide an update of the evidence for intubation in critically ill patients with a focus on understanding peri-intubation risks and evaluating interventions to prevent or mitigate adverse events.

Association Between the Severity of Early Acute Kidney Injury and Subsequent in-Hospital Complications and 90-Day Mortality in Geriatric Patients Receiving Invasive Mechanical Ventilation

Purpose

Acute kidney injury (AKI) in elderly patients is associated with higher hospital mortality. However, the relationship between AKI and peri-intubation complications is unclear.

Methods

This retrospective, observational, multicenter cohort study enrolled 3271 consecutive elderly patients (≥75 years) who received invasive mechanical ventilation (MV) in four medical centers of Chinese PLA General Hospital from 2008 to 2020. AKI was diagnosed according to the 2012 KDIGO criteria by an absolute increase in serum creatinine of ≥26.5 µmol/L within the first 48 hours of MV. We recorded subsequent in-hospital complications, including incident gastrointestinal bleeding, new-onset electrolyte imbalances, severe hypoxemia, hypoalbuminemia, cardiovascular instability and all-cause 90-day mortality.

Results

A total of 1292 patients were included in the final evaluation, with 29.1% presenting AKI (stage 1: 31.4%, stage 2: 35.1%, stage 3: 33.5%). Multiple regression analyses show that more advanced AKI increased the risk of MAP <65 mmHg (stage 1: OR=1.833, P=0.002; stage 2: OR= 4.653, P<0.001; stage 3: OR=4.834, P<0.001) and SBP <90 mmHg (stage 1: OR=1.644, P=0.014; stage 2: OR=3.701, P<0.001; stage 3: OR=5.750, P<0.001), a new need for or requiring an increased dose of vasopressors (stage 1: OR=1.623, P=0.014; stage 2: OR=3.250, P<0.001; stage 3: OR=12.132, P<0.001), gastrointestinal bleeding (stage 1: OR=1.102, P=0.669; stage 2: OR=1.471, P=0.060; stage 3: OR=2.377, P<0.001), severe hypoxia (stage 1: OR=1.213, P=0.399; stage 2: OR=1.449, P=0.077; stage 3: OR=2.214, P<0.001) and all-cause 90-day mortality (stage 1: OR =0.935; P=0.741; stage 2: OR=1.888; P=0.001; stage 3: OR=12.584; P<0.001).

Conclusion

Our study suggests that the presence of AKI within the first 48 hours of MV in geriatric patients is associated with a higher risk for postintubation complications and 90-day mortality. Moreover, the risk of complications was greater for patients with more severe AKI.

Airway management in the critically ill patient with COVID-19

PURPOSE OF REVIEW

Critically ill Coronavirus disease 2019 (COVID-19) patients needing endotracheal intubation are on the verge of rapid decompensation. The aims of this review were to assess the risks, the preoxygenation, the device and the hemodynamic management of a patient with COVID-19.

RECENT FINDINGS

The proceduralist performing endotracheal intubation with the entire team are at an increased risk for exposure to COVID-19. Appropriate personal protective equipment and other measures remain essential. For preoxygenation, noninvasive ventilation allows higher oxygen saturation during intubation in severely hypoxemic patients and can be associated with apneic oxygenation and mask ventilation during apnea in selected cases. The COVID-19 pandemic has further highlighted the place of videolaryngoscopy during intubation in intensive care unit (ICU). Hemodynamic optimization is mandatory to limit hypotension and cardiac arrest associated with airway management.

SUMMARY

Future trials will better define the role of videolaryngoscopy, apneic oxygenation and mask ventilation during apnea for intubation of COVID-19 patients in ICU. The use of fluid loading and vasopressors remains to be investigated in large randomized controlled studies. Choosing the right time for intubation remains uncertain in clinical practice, and future works will probably help to identify earlier the patients who will need intubation.

Endotracheal intubation sedation in the intensive care unit

Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.

Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies

Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.

Airway Management in the Critically Ill Patient

Purpose of Review

This paper will evaluate the recent literature and best practices in airway management in critically ill patients.

Recent Findings

Cardiac arrest remains a common complication of intubation in these high-risk patients. Patients with desaturation or peri-intubation hypotension are at high risk of cardiac arrest, and each of these complications have been reported in up to half of all intubations in critically ill patient populations.

Summary

There have been significant advances in preoxygenation and devices available for performing laryngoscopy and rescue oxygenation. However, the risk of cardiovascular collapse remains concerningly high with few studies to guide therapeutic maneuvers to reduce this risk.

Risk Factors for and Outcomes Associated With Peri-Intubation Hypoxemia: A Multicenter Prospective Cohort Study

BACKGROUND

Little is known about hypoxemia surrounding endotracheal intubation in the critically ill. Thus, we sought to identify risk factors associated with peri-intubation hypoxemia and its effects' on the critically ill.

METHODS

Data from a multicenter, prospective, cohort study enrolling 1,033 critically ill adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 were used to identify risk factors associated with peri-intubation hypoxemia and its effects on patient outcomes. We defined hypoxemia as any pulse oximetry ≤ 88% during and up to 30 minutes following endotracheal intubation.

RESULTS

In the full analysis (n = 1,033), 123 (11.9%) patients experienced the primary outcome. Five risk factors independently associated with our outcome were identified on multiple logistic regression: cardiac related reason for endotracheal intubation (OR 1.67, [95% CI 1.04, 2.69]); pre-intubation noninvasive ventilation (OR 1.66, [95% CI 1.09, 2.54]); emergency intubation (OR 1.65, [95% CI 1.06, 2.55]); moderate-severe difficult bag-mask ventilation (OR 2.68, [95% CI 1.72, 4.19]); and crystalloid administration within the preceding 24 hours (OR 1.24, [95% CI 1.07, 1.45]; per liter up to 4 liters). Higher baseline S_pO₂ was found to be protective (OR 0.93, [95% CI 0.91, 0.96]; per percent up to 97%). Consistent results were seen in a separate analysis on only stable patients (n = 921, 93 [10.1%]) (those without baseline hypoxemia ≤ 88%). Peri-intubation hypoxemia was associated with in-hospital mortality (OR 2.40, [95% CI 1.33, 4.31]; stable patients: OR 2.67, [95% CI 1.38, 5.17]) but not ICU length of stay (point estimate 0.9 days, [95% CI -1.0, 2.8 days]; stable patients: point estimate 1.5 days, [95% CI -0.4, 3.4 days]) after adjusting for age, body mass index, illness severity, airway related reason for intubation (i.e., acute respiratory failure), and baseline S_PO₂.

CONCLUSIONS

Patients with pre-existing noninvasive ventilation and volume loading who were intubated emergently in the setting of hemodynamic compromise with bag-mask ventilation described as moderate-severe were at increased risk for peri-intubation hypoxemia. Higher baseline oxygenation was found to be protective against peri-intubation hypoxemia. Peri-intubation hypoxemia was associated with in-hospital mortality but not ICU length of stay.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.