Incidence of and risk factors for severe cardiovascular collapse after endotracheal intubation in the ICU: a multicenter observational study

Abstract

IntroductionSevere cardiovascular collapse (CVC) is a life-threatening complication after emergency endotracheal intubation (ETI) in the ICU. Many factors may interact with hemodynamic conditions during ETI, but no study to date has focused on factors associated with severe CVC occurrence. This study assessed the incidence of severe CVC after ETI in the ICU and analyzed the factors predictive of severe CVC.MethodsThis was a secondary analysis of a prospective multicenter study of 1,400 consecutive intubations at 42 ICUs. The incidence of severe CVC was assessed in patients who were hemodynamically stable (mean arterial blood pressure >65 mmHg without vasoactive drugs) before intubation, and the factors predictive of severe CVC were determined by multivariate analysis based on patient and procedure characteristics.ResultsSevere CVC occurred following 264 of 885 (29.8 %) intubation procedures. A two-step multivariate analysis showed that independent risk factors for CVC included simple acute physiologic score II regardless of age (odds ratio (OR) 1.02, p < 0.001), age 60–75 years (OR 1.96, p < 0.002 versus <60 years) and >75 years (OR 2.81, p < 0.001 versus <60 years), acute respiratory failure as a reason for intubation (OR 1.51, p = 0.04), first intubation in the ICU (OR 1.61, p = 0.02), noninvasive ventilation as a preoxygenation method (OR 1.54, p = 0.03) and inspired oxygen concentration >70 % after intubation (OR 1.91, p = 0.001). Comatose patients who required ETI were less likely to develop CVC during intubation (OR 0.48, p = 0.004).ConclusionsCVC is a frequent complication, especially in old and severely ill patients intubated for acute respiratory failure in the ICU. Specific bundles to prevent CVC may reduce morbidity and mortality related to intubation of these high-risk, critically ill patients.Trial registrationclinicaltrials.gov NCT01532063; registered 8 February 2012.

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“…Our rate of hypotension is fairly low relative to several other studies (2,10,23) despite a fairly inclusive definition (administration of fluid or phenylephrine bolus, initiation or increase of vasopressor infusion). Moreover, cardiac arrest was extremely uncommon in our population, occurring in 0.57% of intubations.…”

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“…However, this evidence is supported in the surgical setting as there are randomized controlled trials (RCTs), meta-analyses, and systematic reviews. Although the environments are different, neither the techniques for the acquisition of competencies, and in one place as in the other, there are situations of unexpected vital commitment and/or deterioration of respiratory and hemodynamic function [7,21,41,53,54]. Therefore, the results of existing studies in surgical areas can be extrapolated to the field of ICU for many of the above-mentioned plots.…”

“…Peri-OTI hypotension is a risk factor for adverse events, including cardiorespiratory arrest related to the management of AM, and up to 30% of critically ill patients may present post-OTI cardiovascular collapse [21,54,[105][106][107].…”

“…Systolic blood pressure (SBP) <70 mmHg complicates 10% of intubations in ICU patients [9,54,106,107], and when the patient has a preinduction gravity HR/SBP > 0.8, hemodynamic optimization should be performed pre-OTI and use inducing drugs with little response.…”

“…When a patient with right heart failure requires OTI, increased afterload and decreased preload associated with invasive mechanical ventilation often leads to this cardiovascular collapse [21,54,105,107,113,118].…”