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Smischney NJ, Kashyap R, Khanna AK, Brauer E, Morrow LE, Seisa MO, Schroeder DR, Diedrich DA, Montgomery A, Franco PM, Ofoma UR, Kaufman DA, Sen A, Callahan C, Venkata C, Demiralp G, Tedja R, Lee S, Geube M, Kumar SI, Morris P, Bansal V, Surani S. Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study. PLoS One 2020; 15:e0233852. [PMID: 32866219 PMCID: PMC7458292 DOI: 10.1371/journal.pone.0233852] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 05/13/2020] [Indexed: 02/05/2023] Open
Abstract
Objective Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation. Methods A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation. Results Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension. Conclusions A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients. Study registration Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.
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Affiliation(s)
- Nathan J. Smischney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
- * E-mail:
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ashish K. Khanna
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, United States of America
- Department of Anesthesia, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Ernesto Brauer
- Department of Critical Care Medicine, Aurora Health Care, Milwaukee, Wisconsin, United States of America
| | - Lee E. Morrow
- Department of Critical Care Medicine, Creighton University, Omaha, Nebraska, United States of America
| | - Mohamed O. Seisa
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Darrell R. Schroeder
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Daniel A. Diedrich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
- HEModynamic and AIRway Management (HEMAIR) Study Group, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Ashley Montgomery
- Department of Anesthesia and Critical Care Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States of America
| | - Uchenna R. Ofoma
- Division of Critical Care Medicine, Geisinger Health System, Danville, Pennsylvania, United States of America
| | - David A. Kaufman
- Section of Pulmonary, Critical Care, and Sleep Medicine, Bridgeport Hospital/Yale New Haven Health, Bridgeport, Connecticut, United States of America
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic, Scottsdale, Arizona, United States of America
| | - Cynthia Callahan
- Department of Critical Care Medicine, Berkshire Medical Center, Pittsfield, Massachusetts, United States of America
| | - Chakradhar Venkata
- Department of Critical Care Medicine, Mercy Hospital, St. Louis, Missouri, United States of America
| | - Gozde Demiralp
- Department of Anesthesia and Critical Care Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Rudy Tedja
- Department of Critical Care Medicine, Memorial Medical Center, Modesto, California, United States of America
| | - Sarah Lee
- Division of Pulmonary, Critical Care & Sleep Medicine, Detroit Medical Center, Detroit, Michigan, United States of America
| | - Mariya Geube
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Santhi I. Kumar
- Department of Critical Care Medicine, Kerk School University of Southern California, Los Angeles, California, United States of America
| | - Peter Morris
- Department of Anesthesia and Critical Care Medicine, University of Kentucky, Lexington, Kentucky, United States of America
| | - Vikas Bansal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States of America
| | - Salim Surani
- Department of Critical Care Medicine, Corpus Christi Medical Center, Corpus Christi, Texas, United States of America
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ET-26 hydrochloride (ET-26 HCl) has similar hemodynamic stability to that of etomidate in normal and uncontrolled hemorrhagic shock (UHS) rats. PLoS One 2017; 12:e0183439. [PMID: 28813523 PMCID: PMC5557577 DOI: 10.1371/journal.pone.0183439] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/03/2017] [Indexed: 02/05/2023] Open
Abstract
Objective ET-26 HCl is a promising sedative–hypnotic anesthetic with virtually no effect on adrenocortical steroid synthesis. However, whether or not ET-26 HCl also has a sufficiently wide safety margin and hemodynamic stability similar to that of etomidate and related compounds remains unknown. In this study, the effects of ET-26 HCl, etomidate and propofol on therapeutic index, heart rate (HR), mean arterial pressure (MAP), maximal rate for left ventricular pressure rise (Dmax/t), and maximal rate for left ventricular pressure decline (Dmin/t) were investigated in healthy rats and a rat model of uncontrolled hemorrhagic shock (UHS). Methods 50% effective dose (ED50) and 50% lethal dose (LD50) were determined after single bolus doses of propofol, etomidate, or ET-26 HCl using the Bliss method and the up and down method, respectively. All rats were divided into either the normal group and received either etomidate, ET-26 HCl or propofol, (n = 6 per group) or the UHS group and received either etomidate, ET-26 HCl or propofol, (n = 6 per group). In the normal group, after preparation for hemodynamic and heart-function monitoring, rats were administered a dose of one of the test agents twofold-higher than the established ED50, followed by hemodynamic and heart-function monitoring. Rats in the UHS group underwent experimentally induced UHS with a target arterial pressure of 40 mmHg for 1 hour, followed by administration of an ED50 dose of one of the experimental agents. Blood-gas analysis was conducted on samples obtained during equilibration with the experimental setup and at the end of the experiment. Results In the normal group, no significant differences in HR, MAP, Dmax/t and Dmin/t (all P > 0.05) were observed at any time point between the etomidate and ET-26 HCl groups, whereas HR, MAP and Dmax/t decreased briefly and Dmin/t increased following propofol administration. In the UHS group, no significant differences in HR, MAP, Dmax/t and Dmin/t were observed before and after administration of etomidate or ET-26 HCl at ED50 doses (all P > 0.05). Administration of propofol resulted in brief, statistically significant reductions in HR and Dmax/t, with a brief increase in Dmin/t (P ˂ 0.05), while no significant differences in MAP were observed among the three groups. The blood-lactate concentrations of rats in the ET-26 HCl group were significantly lower than those in etomidate and propofol groups (P ˂ 0.05). Conclusions ET-26 HCl provides a similar level of hemodynamic stability to that obtained with etomidate in both healthy rats, and rat models of UHS. ET-26 HCl has the potential to be a novel induction anesthetic for use in critically ill patients.
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