Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study
Vincenzo Russotto, Elena Tassistro, Sheila Nainan Myatra, Matteo Parotto, Laura Antolini, Philippe R. Bauer, Jean-Baptiste Lascarrou, Konstanty Szułdrzyński, Luigi Camporota, Christian Putensen, Paolo Pelosi, Massimiliano Sorbello, A. Higgs, Robert Greif, Antonio Artigas, Maria Grazia Valsecchi, Roberto Fumagalli, Giuseppe Foti, Giacomo Bellani, John G. Laffey
Abstract
Abstract Rationale Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02–1.03), higher heart rate (OR, 1.008; 95% CI, 1.004–1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98–0.99), lower oxygen saturation as measured by pulse oximetry/Fi O2 before induction (OR, 0.998; 95% CI, 0.997–0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05–1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72–3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02–1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84–2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96–1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse. Clinical trial registered with clinicaltrials.gov (NCT03616054).