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

Authors

Nathan J. Smischney, Mayo Clinic
Rahul Kashyap, Mayo Clinic
Ashish K. Khanna, Cleveland Clinic
Ernesto Brauer, Aurora Health Care
Lee E. Morrow, Creighton University
Mohamed O. Seisa, Mayo Clinic
Darrell R. Schroeder, Mayo Clinic
Daniel A. Diedrich, Mayo Clinic
Ashley Montgomery, University of KentuckyFollow
Pablo Moreno Franco, Mayo Clinic
Uchenna R. Ofoma, Geisinger Health System
David A. Kaufman, Bridgeport Hospital
Ayan Sen, Mayo Clinic
Cynthia Callahan, Berkshire Medical Center
Chakradhar Venkata, Mercy Hospital
Gozde Demiralp, University of Oklahoma
Rudy Tedja, Memorial Medical Center
Sarah Lee, Detroit Medical Center
Mariya Geube, Cleveland Clinic
Santhi I. Kumar, University of Southern California
Peter E. Morris, University of KentuckyFollow
Vikas Bansal, Mayo Clinic
Salim Surani, Corpus Christi Medical Center
On behalf of SCCM Discovery (Critical Care Research Network of Critical Care Medicine) HEMAIR Investigators Consortium

Abstract

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 < 65 mmHg; 2) systolic blood pressure < 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 < 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.

Document Type

Article

Publication Date

8-31-2020

Notes/Citation Information

Published in PLOS ONE, v. 15, no. 8, e0233852.

© 2020 Smischney et al.

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Digital Object Identifier (DOI)

https://doi.org/10.1371/journal.pone.0233852

Related Content

All relevant data are within the paper and its Supporting Information files (specifically S8 Table).

All Supporting Information files are available for download as the additional files listed at the end of this record.

Repository Citation

Smischney, Nathan J.; Kashyap, Rahul; Khanna, Ashish K.; Brauer, Ernesto; Morrow, Lee E.; Seisa, Mohamed O.; Schroeder, Darrell R.; Diedrich, Daniel A.; Montgomery, Ashley; Moreno Franco, Pablo; Ofoma, Uchenna R.; Kaufman, David A.; Sen, Ayan; Callahan, Cynthia; Venkata, Chakradhar; Demiralp, Gozde; Tedja, Rudy; Lee, Sarah; Geube, Mariya; Kumar, Santhi I.; Morris, Peter E.; Bansal, Vikas; Surani, Salim; and On behalf of SCCM Discovery (Critical Care Research Network of Critical Care Medicine) HEMAIR Investigators Consortium, "Risk Factors for and Prediction of Post-Intubation Hypotension in Critically Ill Adults: A Multicenter Prospective Cohort Study" (2020). Internal Medicine Faculty Publications. 211.
https://uknowledge.uky.edu/internalmedicine_facpub/211