Predictors of the complication of postintubation hypotension during emergency airway management

• Published in: Journal of critical care 2012-12, Vol.27 (6), p.587-593
• Main Authors: Heffner, Alan C., MD, Swords, Douglas S., BA, MS IV, Nussbaum, Marcy L., MS, Kline, Jeffrey A., MD, Jones, Alan E., MD
• Format: Article
• Language: English
• Subjects: Adult; Age Factors; Aged; Airway management; Blood Pressure; Comorbidity; Complication; Confidence intervals; Core curriculum; Critical Care; Emergency medical care; Emergency Service, Hospital; Family medical history; Female; Hospital Mortality; Humans; Hypotension; Hypotension - diagnosis; Hypotension - epidemiology; Hypotension - etiology; Incidence; Intubation; Intubation, Intratracheal - adverse effects; Kidney diseases; Logistic Models; Male; Middle Aged; Mortality; Post-intubation hypotension; Postoperative Complications - epidemiology; Quality control; Retrospective Studies; Risk Assessment; ROC Curve; Shock index; Studies; Teaching hospitals; Time Factors; Variables; Ventilation
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2012.04.022

Abstract Objective Arterial hypotension is a recognized complication of emergency intubation that is independently associated with increased morbidity and mortality. Our aim was to identify factors associated with postintubation hypotension after emergency intubation. Methods Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements below 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with postintubation hypotension (PIH), defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. Multiple logistic regression modeling was used to define predictors of PIH. Results A total 465 patients underwent emergency intubation during the study period, and 300 met inclusion criteria for this study. Postintubation hypotension occurred in 66 (22%) of 300 patients, and these patients experienced significantly higher in-hospital mortality (35% vs 20%; odds ratio [OR] 2.1; 95% confidence interval [CI], 1.2-3.9). Multiple logistic regression analysis demonstrated that preintubation shock index (SI), chronic renal disease, intubation for acute respiratory failure, and age were independently associated with PIH. Of these, SI was the most strongly associated factor (OR, 55; 95% CI, 13-232). Receiver operating characteristic plot showed optimized SI 0.8 or higher predicting PIH with 67% sensitivity and 80% specificity. Rapid sequence intubation paralysis was associated with a lower incidence of PIH (OR, 0.04; 95% CI, 0.003-0.4). Conclusions Preintubation and peri-intubation factors predict the complication of PIH. Elevated SI strongly and independently forewarned of cardiovascular deterioration after emergency intubation with pre-RSI SI 0.8 or higher as the optimal threshold to identify patients at risk.