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


1
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
2
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.

3
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.

4
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.

5
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.

6
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.

7
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.

8
Patients And Methods
  • Patient characteristics and reasons for intensive
    care unit (ICU) admission.

9
Patients And Methods
  • Operator status and main variables obtained
    before intubation.

10
Patients And Methods
  • Incidence of use of each anesthetic drug for
    endotracheal intubation.

11
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.

12
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.

13
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.

14
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.

15
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.

16
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.

17
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.

18
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.

19
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.

20
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.

21
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.

22
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.

23
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.

24
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.

25
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.

26
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.

27
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)

28
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.

29
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.

30
Thanks for your attention!!
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