Pre intubation vasopressor infusions and the risk of haemodynamic instability following emergency intubation in the ICU

Purpose To determine whether vasopressor use prior to intubation is associated with a reduction in the incidence and severity of hypotension in critically ill patients. Materials and methods We performed a retrospective observational study using two electronic medical record datasets from mixed medical–surgical ICUs in Bern and Amsterdam (HiRiD and UMCDb) between 2003 and 2016. Patients undergoing their first ICU intubation with invasive blood pressure monitoring and ≥15 min of pre- and ≥60 min of post-intubation data were eligible. The primary exposure was continuous vasopressor infusion prior to induction. The primary outcome was the cumulative burden of hypotension, expressed as the area under the curve (AUC) below institutional mean arterial pressure (MAP) targets in the hour following intubation. Propensity score matching and multivariable regression were applied to adjust for confounding. Results Of 2400 screened episodes, 1507 intubations met inclusion criteria (median age 65 years IQR 55–75; 31.9% female). The maximal MAP decrease was −24 mmHg IQR −37 to −14. Severe hypotension (MAP <45 mmHg) occurred in 253 patients (16.8%). Median AUC below target was 27.0 mmHg min IQR 1–82 without vasopressors vs. 50.5 IQR 5–133 with vasopressors; this difference was not significant after matching (Adjusted Mean Difference 7.82 (95% CI -8.4, 24.0). A MAP <75 mmHg before intubation was associated with a higher probability of severe hypotension post-intubation than baseline. Conclusions New hypotension is a common occurrence during intubation, and prophylactic vasopressor infusion prior to intubation did not reduce hypotension burden, however the predicted probability of severe hypotension exceeded the overall incidence when the pre-intubation MAP was below 75 mmHg. Prospective randomized trials are needed to evaluate the use of prophylactic vasopressors prior to intubation.