Peri-intubation hypotension: Intervene early, improve outcomes

A 72-year-old male arrives to the ED in respiratory distress. EMS reports that he is hypoxic with a cough and fever, had no improvement after albuterol, and is now on CPAP. As he is rushed into the room, you note the pause from everyone at the workstation as it’s clear he is now the sickest person in the department. He looks more altered as he pulls at his mask and starts to fight for air. As he is moved off the stretcher, you grab your airway setup and a new set of vitals reveals a BP of 78/50 mmHg. What’s your next move? Do you move forward with the intubation, hoping for a quick first- pass success and deal with the blood pressure later? Start running some fluid “wide open” as you push the RSI medications? Or is there a better way to optimize this patient as quickly as possible to secure the airway and prevent turning your critical patient into a coding one?

In the ED and ICU, peri-intubation hypotension occurs frequently and correlates significantly with morbidity and mortality. Hypotension is an independent risk factor for cardiac arrest, and studies of intubations in critical care patients note an incidence of severe cardiovascular complications of up to 30%.1-4 While the pathophysiology of shock is often multifactorial and complicated by the patient’s underlying illness, the series of actions taken during intubation can abruptly alter or overwhelm the patient’s already tenuous compensatory mechanisms. For example, the introduction of positive pressure ventilation (PPV) can decrease venous return, preload, and cardiac output.5 In addition, circulating endogenous catecholamines helping to maintain cardiac output and vascular tone can be rendered ineffective by rapid pH drops (from respiratory acidosis) and the sympatholytic effects of induction agents.6,7 Many of these factors are inherently unavoidable as we can’t always prevent respiratory failure in patients in shock. Therefore, every effort should be made to rapidly resuscitate the patient immediately to prevent further decompensation and cardiovascular collapse.

Hypoxia, lack of pre-oxygenation, and hypotension (SBP<90mmHg) are three independent modifiable risk factors associated with cardiac arrest related to intubation.8 Many advanced airway courses and techniques exist, such as delayed sequence intubation, which aim to provide adequate pre-oxygenation, minimize apneic time and limit further hypoxia.9 Data for treatment of peri- intubation hypotension, however, is limited. A multi-center study which looked at the benefit of a peri-intubation protocol involving preoxygenation, fluid loading, and preparation of vasoactive agents observed a significant decrease in severe post-intubation cardiovascular collapse (15% vs. 26%) in the study group (Figure 1).10

In particular, the percentage of patients receiving a fluid bolus improved from 49% to 75% and was identified by the authors as having played a key role in improving hemodynamics in the intervention group. As previously discussed in our blog on rapid resuscitation, a rapid fluid bolus can effectively treat hypovolemia and intravascular depletion while augmenting preload to buffer the sudden addition of PPV.

In the case of the 72-year old male described above, this patient needs resuscitation prior to intubation. The presence of hypotension confers a 10-fold increased risk of death during hospitalization and every minute of continued hypotension leads to tissue ischemia that increases risk of organ dysfunction and death.11,12 In the ED, we often face the sickest patients that require immediate action with little or no time to prepare. EMS may have placed an IV, but that is not always the case. Inserting a central line or waiting for a vasopressor drip to come up from pharmacy could be out of the question if they are decompensating. Push-dose pressors are an option, yet not all ED’s or providers are comfortable with their use.13,14 In reality, especially in the community setting, the go-to intervention will be fluids. Yet how effective are current fluid delivery methods for rapid resuscitation? Gravity infusion or hanging saline “wide open” is a passive intervention. It may eventually fix the blood pressure, but the delay will prolong the duration of respiratory distress and increase the risk of organ injury. Lifeflow® is a new method to facilitate rapid, controlled fluid resuscitation. Studies have shown that LifeFlow can deliver an initial 500ml fluid bolus in 2.5 minutes, significantly faster than any traditional method.15,16 LifeFlow can enable clinicians to quickly restore perfusion and see immediate improvement in patient’s heart rate, blood pressure and other measures of shock.

As discussed previously in the Dangers of Passive Resuscitation, time is essential in the treatment of a hypotensive patient. We know that intubating a hypotensive patient confers significant risk of hemodynamic collapse and cardiac arrest. Innovative new techniques, like LifeFlow, may offer us the ability to quickly resolve peri-intubation hypotension with minimal interruption as we’re setting up to secure the airway.

Interested in learning more about LifeFlow? Contact us.


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