Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: A prospective, multiple-center study

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Clinical practice and risk factors for immediate
complications ofendotracheal intubation in the
intensive care unit A prospective,multiple-cente
r study
Crit Care Med 2006 Vol. 34, No. 9Samir Jaber,
MD, PhD Jibba Amraoui, MD

• From intensive care units of DAR B CHU de
  Montpellier, Hôpital Saint Eloi, Université
  Montpellier 1, Montpellier, cedex 5 France
  Groupe Hospitalo-Universitaire Caremeau, Centre
  Hospitalier Universitaire Nîmes, Nîmes cedex 9,
  France.

??? ????? ??? Intern
??? ?? 2011/05/16
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Backgrouds

• In the intensive care unit (ICU), endotracheal
  intubation (ETI) differs significantly from ETI
  carried out for routine surgical procedures.
• In the operating room, most intubations are
  performed under elective controlled conditions by
  anesthesiologists experienced in airway
  management.

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Backgrouds

• Emergency ETI performed outside the operating
  room has been studied more often in prehospital
  settings and in emergency departments.
• Only two studies have focused on the
  complications related to ETI performed in the
  ICU.

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Backgrouds

• Schwartz et al. (1) performed a descriptive study
  in three ICUs of a single institution,
  investigating the complications of emergency
  airway management in 297 critically ill patients
  carried out by the ICU.
• Le Tacon et al. (2), in a prospective cohort
  study, performed a single-center evaluation of
  the frequency of difficult ETI and listed the
  related complications.

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Backgrouds

• No study has focused on potential conditions that
  could be considered as risk factors for
  complications associated with ETI and reported
  associated hemodynamic complications.
• Therefore, a multiple-center observational study
  was performed in seven French ICUs.

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Objectives

• To describe the current practice of physicians.
• To report complications associated with
  endotracheal intubation (ETI) performed in the
  intensive care unit (ICU).
• To isolate predictive factors of immediate
  life-threatening complications.

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Patients And Methods

• Design Multiple-center observational study.
• Setting Seven intensive care units of two
  university hospitals.
• Patients We evaluated 253 occurrences of ETI in
  220 patients.
• Interventions From January 1 to June 30, 2003,
  data related to all ETI performed in ICU were
  collected. Information regarding patient
  descriptors, procedures, and immediate
  complications were analyzed.

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Patients And Methods

• Patient characteristics and reasons for intensive
  care unit (ICU) admission.

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Patients And Methods

• Operator status and main variables obtained
  before intubation.

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Patients And Methods

• Incidence of use of each anesthetic drug for
  endotracheal intubation.

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Results

• During the study period, 1,650 patients were
  admitted in the 85 beds of the seven ICUs.
• The mean rate of intubated patients in the seven
  ICUs was 74 (1,221 of 1,650). 263 intubations
  were performed in the ICU (22). Ten could not be
  analyzed because data were missing or
  incomplete.
• Therefore, the present study included 253 ETIs in
  220 patients.

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Results

• The main indications to intubate the trachea
  were acute respiratory failure, shock, and coma.
• ETIs were performed by oral or nasal route in 246
  and seven patients, respectively.
• Seventy-five percent of intubations were done on
  the first attempt, 13 required two attempts, 9
  required three attempts, and 3 required at least
  four attempts.

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Results

• The patients with severe ETI complications
  compared with those with no ETI complications
  were significantly (1) Older age.(2) Higher
  SAPS II. (3) More precarious hemodynamic status
  as evidenced by shock being a more
  prevalent reason for ICU admission.(4)
  Lower systolic blood pressure.(5) Increased
  fluid loading requirement(6) Increased
  vasopressor use.

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Results

• The two categories of ETI complications (severe
  life-threatening and mild to moderate
  complications) are shown in Figure 1.
• 148 ETIs (59) were performed by residents. At
  least one severe complication occurred in 71 ETIs
  (28) severe hypoxemia in 66 ETIs (26),
  hemodynamic collapse in 65 ETIs (25), and
  cardiac arrest in 4 ETIs (1.6), Death in 2 ETIs.

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Results

• The other complications were difficult intubation
  (12), cardiac arrhythmia (10), esophageal
  intubation (5), and aspiration (2).
• Esophageal intubations were always diagnosed with
  auscultation leading to immediate reintubation
  without any oxygen desaturation.

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Results

• The mean decreases in the highest and lowest
  systolic blood pressure values obtained before
  and during or immediately after the ETI attempt
  are presented in Figures 2 and 3.

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Results

• The mean decreases in lowest pulse oxygen
  saturation calculated between the values before
  and during the procedure for patients with
  complicated ETI and those with no complication
  are presented in Figure 4.

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Results

• The lower the systolic blood pressure was before
  the intubation, the higher the risk of having an
  ETI complication.
• The other independent risk factor for ETI
  complication was acute respiratory failure as a
  reason for intubation.
• An ETI attempt performed by a resident who was
  always supervised by a senior (i.e., two
  operators) was found to be the protective factor
  for the ETI complication occurrence.

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Results

• The main outcomes of the 220 included ICU
  patients are shown in Table 5.
• The patients who had serious complications had a
  significantly higher mortality rate than the
  patients who did not have complications.

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Discussion- ETI practice

• 88 of the 253 ETIs were performed in emergency
  or in relative emergency conditions.
• Etomidate was the most common hypnotic agent
  (50) used, and succinylcholine was the
  neuromuscular blocker (69) most used.

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Discussion- ETI practice

• Etomidate has become the induction agent of
  choice in many institutions because of its
  hemodynamic safety profile.
• The use of neuromuscular blockers, especially
  nondepolarizing agents induce prolonged paralysis
  with no spontaneous respiration. This exexplain
  why succinylcholine was more commenly used.

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Discussion

• Complications occurred in nearly half of the
  patients, and serious complications occurred in
  28.
• The most frequent of them were hypotension
  leading to a frequent use of vasopressor and
  severe hypoxemia.
• The complications of ETI did not differ by
  location or time of day of the procedure.

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Discussion

• Hypotension and acute respiratory failure were
  independent risk factors for complications,
  whereas an ETI performed by a junior supervised
  by senior physician was a protective factor.
• The presence of at least two operators improved
  the conditions of the procedure. In other words,
  a second pair of hands is often useful in helping
  to manage a difficult situation.

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Discussion

• In fact, the two main risk factors for immediate
  complications after tracheal intubation are
  precisely the two main indications for tracheal
  intubation.
• In other words, if tracheal intubation is
  justified because of shock or acute respiratory
  failure, tracheal intubation may result in severe
  hemodynamic collapse or severe hypoxemia.

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Limitations

• The data were self-reported by the persons who
  performed the ETI, so the degree of intubation
  difficulty may have been underestimated or
  overestimated.
• Because patients were not randomly assigned to
  different methods of intubation, the success
  rates and rates of immediate complications for
  the different methods must be interpreted with
  caution.

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Limitations

• Because the observed complications may be due to
  the severity of illness of the patient, we chose
  very extreme definitions of collapse due to ETI
  and severe hypoxemia.
• We did not record the dose of total administered
  drugs used for ETI, and we cannot evaluate the
  correlation with the degree of hypotension
  occurring after the attempt.

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Conclusion

• This prospective multiple-center study of 253
  endotracheal intubations performed in ICU showed
  a high frequency of serious life-threatening
  complications (28) including(1) Severe
  hypotension (26)(2) Severe hypoxemia (25)(3)
  Cardiac arrest (1.6)(4) Death (0.8)

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Conclusion

• Presence of acute respiratory failure and
  presence of shock as an indication for ETI were
  identified as independent risk factors of
  complication occurrence.
• ETI performed by a junior physician supervised by
  a senior (i.e., two operators) was identified as
  a protective effect of ETI complication
  occurrence.

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Conclusion

• Further studies should aim to better define
  protocols (drugs, dosage, rapid sequence
  induction, systematic loading) for endotracheal
  intubation in critically ill patients to make
  this procedure safer.

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Thanks for your attention!!