Intubation During Transport Ups Hemodynamic Collapse Risk

TOPLINE: 

Intubation during critical care transport is associated with a high incidence of hemodynamic collapse, including life-threatening situations. The pre-intubation shock index predicts risk.

METHODOLOGY:

• Researchers conducted a retrospective chart review of 333 adult patients (mean age, 52 years; 71.8% men) who were intubated endotracheally by a critical care transport team at a rural academic medical center in the United States between January 2017 and May 2023.
• Transport was performed using helicopters and ground service.
• The primary outcome was the incidence of hemodynamic collapse, which was defined as a systolic blood pressure (SBP) < 90 mmHg for > 30 minutes, new vasopressor infusion requirement, vasopressor infusion dose increase, or a fluid bolus > 15 mL/kg as well as an SBP < 65 mmHg at least once or cardiac arrest.
• The secondary outcomes were the presence of postintubation hypoxia and associations of hemodynamic collapse with modifiable risk factors such as the induction agent and pre-intubation shock index, heart rate, and SBP.

TAKEAWAY:

• Hemodynamic collapse occurred in 29.1% patients and life-threatening collapse was experienced by 10.8% patients, indicating a high incidence in patients intubated during critical care transport.
• An elevated shock index (> 1) prior to intubation was significantly associated with an increased risk for hemodynamic collapse (adjusted odds ratio, 3.18; 95% CI, 1.15-8.74).
• Pre-intubation tachycardia and hypotension were not associated with the risk for hemodynamic collapse after adjusting for other variables.
• The choice of induction agent, fluid bolus prior to intubation, location of intubation, presence of traumatic injury, and age were not correlated with the risk for hemodynamic collapse.

IN PRACTICE:

“Shock index is not discussed in these [current] guidelines and was the only potentially modifiable variable to carry a significantly increased risk of hemodynamic collapse and life-threatening hemodynamic collapse in our analysis,” the authors wrote. ” Attention to shock index prior to induction could identify patients who would benefit from intubation delay for further resuscitation or even electing not to intubate,” they added.

SOURCE:

The study was led by Kalle J. Fjeld, Department of Emergency Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire. It was published online on August 27, 2024, in Prehospital Emergency Care.

LIMITATIONS:

Study limitations included its 6-year retrospective design with some missing data on vital signs and fluid and medication administration due to challenges in real-time recording during transport. The study was conducted at a single center on predominantly male and traumatically injured patients, limiting the generalizability of the findings. Additionally, the data abstractors were not blinded to the study outcome. The lack of inter-rater reliability assessment may have further limited the robustness of the data abstraction process. Finally, patient outcomes were not assessed, and standard reporting of the severity of illness was not available, which may have affected the interpretation of the results.

DISCLOSURES:

The study did not receive any funding. The authors declared that they had no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.