Risk Factors for and Prediction of Post-Intubation Hypotension in Critically Ill Adults: A Multicenter Prospective Cohort Study

OBJECTIVE: Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation. METHODS: A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure \u3c 65 mmHg; 2) systolic blood pressure \u3c 80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation. RESULTS: Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure \u3c 65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension. CONCLUSIONS: A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients. STUDY REGISTRATION: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101

Elevated modified shock index in early sepsis is associated with myocardial dysfunction and mortality.

PURPOSE: The aim of this study was to explore the association of an elevated modified shock index (MSI) in sepsis and myocardial dysfunction. METHODS: This single center exploratory retrospective cohort study was conducted at Mayo Clinic from 2011 to 2014. It includes adults admitted to the medical intensive care unit with severe sepsis or septic shock. The time MSI\u3e1.3, area under the curve, in the first 6h was assessed using logistic regression for primary outcomes of myocardial dysfunction and depression and secondary outcomes including mortality and SOFA score. RESULTS: Overall 578 individuals met inclusion criteria, 169 (29%) developed myocardial dysfunction and 23 (4%) myocardial depression. Adjusted for age, gender, Charlson score, and baseline APACHE 3 score, area MSI\u3e1.3 was associated with increased odds of myocardial dysfunction (OR 1.10, 95% CI 1.00-1.21; p=0.058) and depression (OR 1.28, 95% CI 1.07-1.53; p=0.007). Associations were also seen with ICU mortality (OR 1.17, 95% CI 1.04-1.32; p=0.011), hospital mortality (OR 1.13, 95% CI 1.02-1.25; p=0.025) and SOFA score. CONCLUSION: Elevated modified shock index during early sepsis is associated with the development of myocardial dysfunction and depression, SOFA score and mortality

Effect of Ketamine/Propofol Admixture on Peri-Induction Hemodynamics: A Systematic Review and Meta-Analysis

To evaluate the effectiveness of an admixture of ketamine and propofol on peri-induction hemodynamics during airway manipulation, we searched electronic databases of randomized controlled trials from January 1, 2000, to October 17, 2018. Trial screening, selection, and data extraction were done independently by two reviewers with outcomes pooled across included trials using the random-effects model. We included 10 randomized trials (722 patients, mean age of 53.99 years, 39.96% female). American Society of Anesthesiologists physical status was reported in 9 trials with classes I and II representing the majority. Ketamine/propofol admixture was associated with a nonsignificant increase in heart rate (weighted mean difference, 3.36 beats per minute (95% CI, −0.88, 7.60), I2 = 88.6%), a statistically significant increase in systolic blood pressure (weighted mean difference, 9.67 mmHg (95% CI, 1.48, 17.86), I2 = 87.2%), a nonsignificant increase in diastolic blood pressure (weighted mean difference, 2.18 mmHg (95% CI, −2.82, 7.19), I2 = 73.1%), and a nonsignificant increase in mean arterial pressure (weighted mean difference, 3.28 mmHg (95% CI, −0.94, 7.49), I2 = 69.9%) compared to other agents. The risk of bias was high and the certainty of evidence was low. In conclusion, among patients undergoing airway manipulation and needing sedation, the use of a ketamine/propofol admixture may be associated with better hemodynamics compared to nonketamine/propofol sedation. This trial is registered with CRD42019125725

Supplemental Material, Appendix_1_HEMAIR_Survey - Survey on the Current State of Endotracheal Intubation Among the Critically Ill

<p> Supplemental Material, Appendix_1_HEMAIR_Survey for Survey on the Current State of Endotracheal Intubation Among the Critically Ill by Mohamed O. Seisa, Venkatesh Gondhi, Onur Demirci, Daniel A. Diedrich, Rahul Kashyap, and Nathan J. Smischney in Journal of Intensive Care Medicine </p

Risk factors for and outcomes associated with peri-intubation hypoxemia: A multicenter prospective cohort study

BACKGROUND: Little is known about hypoxemia surrounding endotracheal intubation in the critically ill. Thus, we sought to identify risk factors associated with peri-intubation hypoxemia and its effects\u27 on the critically ill. METHODS: Data from a multicenter, prospective, cohort study enrolling 1,033 critically ill adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 were used to identify risk factors associated with peri-intubation hypoxemia and its effects on patient outcomes. We defined hypoxemia as any pulse oximetry ≤ 88% during and up to 30 minutes following endotracheal intubation. Results: In the full analysis (n = 1,033), 123 (11.9%) patients experienced the primary outcome. Five risk factors independently associated with our outcome were identified on multiple logistic regression: cardiac related reason for endotracheal intubation (OR 1.67, [95% CI 1.04, 2.69]); pre-intubation noninvasive ventilation (OR 1.66, [95% CI 1.09, 2.54]); emergency intubation (OR 1.65, [95% CI 1.06, 2.55]); moderate-severe difficult bag-mask ventilation (OR 2.68, [95% CI 1.72, 4.19]); and crystalloid administration within the preceding 24 hours (OR 1.24, [95% CI 1.07, 1.45]; per liter up to 4 liters). Higher baseline SpO2 was found to be protective (OR 0.93, [95% CI 0.91, 0.96]; per percent up to 97%). Consistent results were seen in a separate analysis on only stable patients (n = 921, 93 [10.1%]) (those without baseline hypoxemia ≤ 88%). Peri-intubation hypoxemia was associated with in-hospital mortality (OR 2.40, [95% CI 1.33, 4.31]; stable patients: OR 2.67, [95% CI 1.38, 5.17]) but not ICU length of stay (point estimate 0.9 days, [95% CI -1.0, 2.8 days]; stable patients: point estimate 1.5 days, [95% CI -0.4, 3.4 days]) after adjusting for age, body mass index, illness severity, airway related reason for intubation (i.e., acute respiratory failure), and baseline SPO2. CONCLUSIONS: Patients with pre-existing noninvasive ventilation and volume loading who were intubated emergently in the setting of hemodynamic compromise with bag-mask ventilation described as moderate-severe were at increased risk for peri-intubation hypoxemia. Higher baseline oxygenation was found to be protective against peri-intubation hypoxemia. Peri-intubation hypoxemia was associated with in-hospital mortality but not ICU length of stay. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101

Trajectory of PaO/FiO Ratio in Shock After Angiotensin II

INTRODUCTION: High-dose catecholamines can impair hypoxic pulmonary vasoconstriction and increase shunt fraction. We aimed to determine if Angiotensin II (Ang-2) is associated with improved PaO/FiO and SpO/FiO in patients in shock. METHODS: Adult patients at four tertiary care centers and one community hospital in the United States who received Ang-2 from July 2018-September 2020 were included in this retrospective, observational cohort study. PaO, SpO, and FiO were measured at 13 timepoints during the 48-h before and after Ang-2 initiation. Piecewise linear mixed models of PaO/FiO and SpO/FiO were created to evaluate hourly changes in oxygenation after Ang-2 initiation. The difference in the proportion of patients with PaO/FiO ≤ 300 mm Hg at the time of Ang-2 initiation and 48 h after was also examined. RESULTS: The study included 254 patients. In the 48 h prior to Ang-2 initiation, oxygenation was significantly declining (hourly PaO/FiO change -4.7 mm Hg/hr, 95% CI - 6.0 to -3.5,  \u3c .001; hourly SpO/FiO change -3.1/hr, 95% CI-3.7 to -2.4,  \u3c .001). Ang-2 treatment was associated with significant improvements in PaO/FiO and SpO/FiO in the 48-h after initiation (hourly PaO/FiO change +1.5 mm Hg/hr, 95% CI 0.5-2.5,   =  .003; hourly SpO/FiO change +0.9/hr, 95% CI 0.5-1.2,  \u3c .001). The difference in the hourly change in oxygenation before and after Ang-2 initiation was also significant ( \u3c 0.001 for both PaO/FiO and SpO/FiO). This improvement was associated with significantly fewer patients having a PaO/FiO ≤ 300 mm Hg at 48 h compared to baseline (mean difference -14.9%, 95% CI -25.3% to -4.6%,   =  .011). Subgroup analysis found that patients with either a baseline PaO/FiO ≤ 300 mm Hg or a norepinephrine-equivalent dose requirement \u3e0.2 µg/kg/min had the greatest associations with oxygenation improvement. CONCLUSIONS: Ang-2 is associated with improved PaO/FiO and SpO/FiO. The mechanisms for this improvement are not entirely clear but may be due to catecholamine-sparing effect or may also be related to improved ventilation-perfusion matching, intrapulmonary shunt, or oxygen delivery

MOESM4 of Vasopressor use as a surrogate for post-intubation hemodynamic instability is associated with in-hospital and 90-day mortality: a retrospective cohort study

Additional file 4: Table S4. Comparison of in-hospital and 90-day mortality between those patients labeled as hemodynamically stable (unexposed) and those labeled as hemodynamically unstable (exposed)

Comparison of Ocular Ultrasonography and Magnetic Resonance Imaging for Detection of Increased Intracranial Pressure

Background/aimsTo evaluate and compare the performance of ocular ultrasonography (US) and magnetic resonance imaging (MRI) for detecting increased intracranial pressure (ICP) in patients with idiopathic intracranial hypertension (IIH).MethodsTwenty-two patients with papilledema from IIH and 22 with pseudopapilledema were prospectively recruited based on funduscopic and clinical findings. Measurements of optic nerve sheath diameters (ONSDs) 3 mm behind the inner sclera were performed on B-scan US and axial T2-weighted MRI examinations. Pituitary-to-sella height ratio (pit/sella) was also calculated from sagittal T1-weighted MRI images. Lumbar puncture was performed in all patients with IIH and in five patients with pseudopapilledema.ResultsAverage US and MRI ONSD were 4.4 (SD ± 0.7) and 5.2 ± 1.4 mm for the pseudopapilledema group and 5.2 ± 0.6 and 7.2 ± 1.6 mm for the papilledema group (p &lt; 0.001). Average MRI pit/sella ratio was 0.7 ± 0.3 for the pseudopapilledema group and 0.3 ± 0.2 for the papilledema group (p &lt; 0.001). Based on receiver-operator curve analysis, the optimal thresholds for detecting papilledema are US ONSD &gt; 4.8 mm, MRI ONSD &gt; 6.0 mm, and MRI pit/sella &lt; 0.5. Combining a dilated US ONSD or MRI ONSD with a below-threshold MRI pit/sella ratio yielded a sensitivity of 73% and specificity of 96% for detecting IIH. Adding the US ONSD to the MRI ONSD and pit/sella ratio only increased the sensitivity by 5% and did not change specificity.ConclusionUS and MRI provide measurements of ONSD that are well-correlated and sensitive markers for increased ICP. The combination of the ONSD and the pit/sella ratio can increase specificity for the diagnosis of IIH