Clinical practice and risk factors for iClinical practice and risk factors for immediate complications ofmmediate complications of

endotracheal intubation in the intensivendotracheal intubation in the intensive care unit: A prospective,e care unit: A prospective,

multiple-center studymultiple-center study

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

Crit Care Med 2006 Vol. 34, No. 9

Samir Jaber, MD, PhD; Jibba Amraoui, MD

指導者 : 葉育彰醫師 報告者 : Intern 林宇力 日期 : 2011/05/16

BackgroudsBackgrouds

• 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.

BackgroudsBackgrouds

• 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.

BackgroudsBackgrouds

• 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.

BackgroudsBackgrouds

• 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.

ObjectivesObjectives

• 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.

Patients And MethodsPatients And Methods

• Design: Multiple-center observational study.• Setting: Seven intensive care units of two univer

sity hospitals.• Patients: We evaluated 253 occurrences of ETI i

n 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.

Patients And MethodsPatients And Methods

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

Patients And MethodsPatients And Methods

• Operator status and main variables obtained before intubation.

Patients And MethodsPatients And Methods

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

ResultsResults

• 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.

ResultsResults

• 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.

ResultsResults

• 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.

ResultsResults

• 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.

ResultsResults

• 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.

ResultsResults

• 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.

ResultsResults

• 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.

ResultsResults

• 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.

ResultsResults

• 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.

Discussion- Discussion- ETI practiceETI 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.

Discussion- Discussion- ETI practiceETI 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.

DiscussionDiscussion

• 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.

DiscussionDiscussion

• 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.

DiscussionDiscussion

• 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.

LimitationsLimitations

• 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.

LimitationsLimitations

• 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.

ConclusionConclusion

• 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%)

ConclusionConclusion

• 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.

ConclusionConclusion

• 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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