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Journal of Anesthesia

, Volume 33, Issue 3, pp 454–462 | Cite as

Emergent endotracheal intubation associated cardiac arrest, risks, and emergency implications

  • Johnnatan Marin
  • Danielle Davison
  • Ali PourmandEmail author
Review Article

Abstract

Emergent endotracheal intubation (ETI)-related cardiac arrest (CA) is a life-threatening complication that is poorly documented. Definitions and risk factors for CA during or directly after emergent ETI have not been clearly established and may represent modifiable means of improving patient outcomes. We conducted a review of the literature to assess the incidence and risk factors associated with ETI-related CA in the Emergency Department (ED) as well as in the inpatient setting outside of the operating room. Retrospective studies demonstrated that ETI-related CA incidence was between 1.7% and 23% in both the ED and the inpatient setting. Pre-intubation hypoxemia, hypotension, Shock Index (SI), Body Mass Index, and age were most associated with CA. Medications used for induction and number of attempts were identified as risk factors. Definitions of ETI-related CA also varied considerably ranging from within 5 min to within 60 min of intubation; however, the majority of ETI-related CA cases occurred within 10 min. Hemodynamic factors such as SI, hypotension, and hypoxemia were associated with increased rates of CA. ETI-related CA may represent a potentially modifiable complication that can improve patient outcomes in critically ill patients presenting in the ED.

Keywords

Emergent Endotracheal intubation Cardiac arrest Risk factors 

Notes

Funding

This study was not funded.

Compliance with ethical standards

Conflict of interest

No competing financial interests exist.

References

  1. 1.
    Schwab TD, Greaves TH. Cardiac arrest as a possible sequela of critical airway management and intubation. Am J Emerg Med. 1998;16(6):609–12.CrossRefPubMedGoogle Scholar
  2. 2.
    Walls RM, Brown CA, Bair AE, Pallin DJ. Emergency airway management: a multi center report of 8937 emergency department intubations. J Emerg Med. 2011;41(4):347–54.CrossRefPubMedGoogle Scholar
  3. 3.
    Graham CA, Beard D, Oglesby AJ, Thakore SB, Beale JP, Brittliff J, Johnston MA, McKeown DW, Parke TR. Rapid sequence intubation in scottish urban emergency departments. Emerg Med J. 2003;20(1):3–5.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    De Jong A, Rolle A, Molinari N, Paugam-Burtz C, Constantin JM, Lefrant JY, Asehnoune K, Jung B, Futier E, Chanques G, Azoulay E, Jaber S. Cardiac arrest and mortality related to intubation procedure in critically Ill adult patients: a multicenter cohort study. Crit Care Med. 2018;46(4):532–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Ko BS, Ahn R, Ryoo SM, Ahn S, Sohn CH, Seo DW, Lim KS, Kim WY. Incidence and outcomes of endotracheal intubation-related cardiac arrest in the ED. Am J Emerg Med. 2011;33(11):1642–5.CrossRefGoogle Scholar
  6. 6.
    Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84(11):1500–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Kim WY, Kwak MK, Ko BS, Yoon JC, Sohn CH, Lim KS, Andersen LW, Donnino MW. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One. 2014;9(11):e112779.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Wardi G, Villar J, Nguyen T, Vyas A, Pokrajac N, Minokadeh A, Lasoff D, Tainter C, Beitler JR, Sell RE. Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation. Resuscitation. 2017;121:76–80.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99:607–13.CrossRefPubMedGoogle Scholar
  10. 10.
    Sakles JC, Javedani PP, Chase E, Garst-Orozco J, Gullen-Rodriguez J, Stolz U. The use of a video laryngoscope by emergency medicine residents is associated with a reduction in esophageal intubations in the emergency department. Acad Emerg Med. 2015;22:700–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Zuercher M, Ummenhofer W. Cardiac arrest during anesthesia. Curr Opin Crit Care. 2008;14:269–74.CrossRefPubMedGoogle Scholar
  12. 12.
    Wallmuller G, Meron G, Kurkciyan I, Schober A, Stratil P, Sterz F. Causes of in-hospital cardiac arrest and influence on outcome. Resuscitation. 2012;83:1206–11.CrossRefPubMedGoogle Scholar
  13. 13.
    Mort TC. The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA guidelines in the remote location. J Clin Anesth. 2004;16(7):508–16.CrossRefPubMedGoogle Scholar
  14. 14.
    Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations—part I. J Intensive Care Med. 2007;22:157–65.CrossRefPubMedGoogle Scholar
  15. 15.
    Low JM, Harvey JT, Prys-Roberts C, Dagnino J. Studies of anaesthesia in relation to hypertension VII: adrenergic responses to laryngoscopy. Br J Anaesth. 1986;58:471–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Masato K, Makoto F, Shino T, Masafumi T, Masahiko M, Koji S. Hemodynamic and catecholamine responses during tracheal intubation using a lightwand device (trachlight) in elderly patients with hypertension. J Anesth. 2003;17:161–5.CrossRefGoogle Scholar
  17. 17.
    Shafi S, Gentilello L. Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank. J Trauma. 2005;59:1140–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway. J Crit Care. 2012;27:587–93.CrossRefPubMedGoogle Scholar
  19. 19.
    Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;417:419–413.Google Scholar
  20. 20.
    Franklin C, Samuel J, Hu TC. Life-threatening hypotension associated with emergency intubation and the initiation of mechanical ventilation. Am J Emerg Med. 1994;12:425–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, Bodian CA. Predictors of hypotension after induction of general anesthesia. Anesth Analg. 2005;101:622–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Kim JM, Shin TG, Hwang SY, Yoon H, Cha WC, Sim MS, Jo IJ, Song KJ, Rhee JE, Jeong YK. Sedative dose and patient variable impacts on postintubation hypotension in emergency airwaymanagement. Am J Emerg Med. 2018;.  https://doi.org/10.1016/j.ajem.2018.09.015.CrossRefPubMedGoogle Scholar
  23. 23.
    Sutera PT, Smith CE. Asystole during direct laryngoscopy and tracheal intubation. J Cardiothorac Vasc Anesth. 1994;8:79–80.CrossRefPubMedGoogle Scholar
  24. 24.
    Jones P, Dauger S, Peters MJ. Bradycardia during critical care intubation: mechanisms, significance and atropine. Arch Dis Child. 2012;97(2):139–44.CrossRefPubMedGoogle Scholar
  25. 25.
    Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, Verzilli D, Jonquet O, Eledjam JJ, Lefrant JY. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36(2):248–55.CrossRefPubMedGoogle Scholar
  26. 26.
    Rose DK, Cohen MM. The incidence of airway complications depends on the definition used. Can J Anaesth. 1996;43(1):30–4.CrossRefPubMedGoogle Scholar
  27. 27.
    Uribe AA, Zvara DA, Puente EG, Otey AJ, Zhang J, Bergese SD. BMI as a predictor for potential difficult tracheal intubation in males. Front Med 2015;2(38).Google Scholar
  28. 28.
    Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on management of the difficult airway. Anesthesiology. 2013;118(2):251–70.CrossRefPubMedGoogle Scholar
  29. 29.
    Saasouh W, Laffey K, Turan A, Avitsian R, Zura A, Et. al. Degree of obesity is not associated with more than one intubation attempt: a large centre experience. Br J Anaesth. 2018;120(5):1110–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal intubation. Anesth Analg. 2002;94:732–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, Desmonts JM. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600.CrossRefPubMedGoogle Scholar
  32. 32.
    Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429–37.CrossRefPubMedGoogle Scholar
  33. 33.
    Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3423 emergent tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011;114(1):42–8.CrossRefPubMedGoogle Scholar
  34. 34.
    Collins JS, Lemmens HJM, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “Sniff” and “Ramped” positions. Obes Surg. 2004;14:1171–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Derbyshire DR, Chmielewski D, Fell M, Vater K, Smith A, Smith G. Plasma catecholamine responses to endotracheal intubation. Br J Anaesth. 1983;5(9):855–60.CrossRefGoogle Scholar
  36. 36.
    Imamura T, Brown CA, Ofuchi H, Yamagami H, Branch J, Hagiwara Y. Emergency airway management in geriatric and younger patients: analysis of a multicenter prospective observational study. Am J Emerg Med. 2013;31:190–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Kurnaz MM, Sarıtaş A. Comparison of the effects of truview PCD™ video laryngoscopy and macintosh blade direct laryngoscopy in geriatric patients. J Clin Anesth. 2016;35:268–73.CrossRefPubMedGoogle Scholar
  38. 38.
    Johnson KN, Botros DB, Groban L, Bryan Y. Anatomic and physiopathologic changes affecting the airway of the elderly patient: implications for geriatric-focused airway management. Clin Interv Aging. 2015;10:1925–34.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Esler MD, Thompson JM, Kaye DM, Turner AG, Jennings GL, Cox HS, Lambert GW, Seals DR. Effects of Aging on the responsiveness of the human cardiac sympathetic nerves to stressors. Circulation. 1995;91(2):351–8.CrossRefPubMedGoogle Scholar
  40. 40.
    Habib AS, Parker JL, Maguire AM, Rowbotham DJ, Thompson JP. Effects of remifentanil and alfentanil on the cardiovascular responses to induction of anaesthesia and tracheal intubation in the elderly. Br J Anaesth. 2002;88(3):430–3.CrossRefPubMedGoogle Scholar
  41. 41.
    Zaugg M, Tagliente T, Lucchinetti E, Jacobs E, Krol M, Bodian C, Reich DL, Silverstein JH. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology. 1999;91(6):1674–86.CrossRefPubMedGoogle Scholar
  42. 42.
    Blanie´ A, Ract C, Leblanc PE, Cheisson GI, Huet O, Laplace C. The limits of succinylcholine for critically Ill patients. Anesth Analg. 2012;115:873–9.CrossRefPubMedGoogle Scholar
  43. 43.
    Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations—part II. J Intensive Care Med. 2007;22:208–15.CrossRefPubMedGoogle Scholar
  44. 44.
    Hasegawa K, Shigemitsu K, Hagiwara Y, Chiba T, Watase H, Brown CA 3rd, Brown DF. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60:749–54.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2019

Authors and Affiliations

  • Johnnatan Marin
    • 1
  • Danielle Davison
    • 2
  • Ali Pourmand
    • 1
    Email author
  1. 1.Department of Emergency MedicineGeorge Washington University School of Medicine and Health SciencesWashingtonUSA
  2. 2.Department of Anesthesiology and Critical Care MedicineGeorge Washington University School of Medicine and Health SciencesWashingtonUSA

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