Interventions affecting blood pressure variability and outcomes after intubating patients with spontaneous intracranial hemorrhage

• Published in: The American journal of emergency medicine 2019-09, Vol.37 (9), p.1665-1671
• Main Authors: Tuteja, Gurshawn, Uppal, Angad, Strong, Jonathan, Nguyen, Tina, Pope, Kanisha, Jenkins, Ryne, Al Rebh, Heba, Gatz, David, Chang, Wan-Tsu, Tran, Quincy K.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Anesthesia; Blood Gas Analysis; Blood pressure; Blood Pressure - physiology; Capnography; Carbon dioxide; Cerebral Hemorrhage - physiopathology; Cerebral Hemorrhage - therapy; Coma; Data collection; Emergencies; Emergency medical care; Emergency medical services; Female; Health care facilities; Hemorrhage; Humans; Hypnotics and Sedatives - therapeutic use; Intervention; Intracranial Hemorrhages - physiopathology; Intracranial Hemorrhages - therapy; Intracranial Hypertension - physiopathology; Intracranial Hypertension - therapy; Intracranial pressure; Intubation; Intubation, Gastrointestinal; Intubation, Intratracheal; Male; Mechanical ventilation; Middle Aged; Mortality; Patients; Radiography; Radiography, Thoracic; Respiration, Artificial - methods; Retrospective Studies; Standard deviation; Subarachnoid Hemorrhage - physiopathology; Subarachnoid Hemorrhage - therapy; Survival; Tidal Volume; Trauma; Urinary Catheterization; Ventilators; Ventriculostomy
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2018.11.041

Spontaneous intracranial hemorrhage (sICH) that increases intracranial pressure (ICP) is a life-threatening emergency often requiring intubation in Emergency Departments (ED). A previous study of intubated ED patients found that providing ≥5 interventions after initiating mechanical ventilation (pMVI) reduced mortality rate. We hypothesized that pMVIs would lower blood pressure variability (BPV) in patients with sICH and thus improve survival rates and neurologic outcomes. We performed a retrospective study of adults, who were transferred to a quaternary medical center between 01/01/2011 and 09/30/2015 for sICH, received an extraventricular drain during hospitalization. They were identified by International Classification of Diseases, version 9 (430.XX, 431.XX), and procedure code 02.21. Outcomes were BPV indices, death, and being discharged home. We analyzed records from 147 intubated patients transferred from 40 EDs. Forty-one percent of patients received ≥5 pMVIs and was associated with lower median successive variation in systolic blood pressure (BPSV) (31,[IQR 18–45) compared with those receiving 4 or less pMVIs (38[IQR 16–70]], p = 0.040). Three pMVIs, appropriate tidal volume, sedative infusion, and capnography were significantly associated with lower BPV. In addition to clinical factors, BPSV (OR 26; 95% CI 1.2, >100) and chest radiography (OR 0.3; 95% CI 0.09, 0.9) were associated with mortality rate. Use of quantitative capnography (OR 8.3; 95%CI, 4.7, 8.8) was associated with increased likelihood of being discharged home. In addition to disease severity, individual pMVIs were significantly associated with BPV and patient outcomes. Emergency physicians should perform pMVIs more frequently to prevent BPV and improve patients' outcomes.