ICU doc: “Peri-intubation arrest is incredibly rare”

[u/Ineffaboble]

AITA?

I had a patient with a very bizarre presentation of flash pulmonary edema brady down and arrest after a crash intubation for sats heading down to 65% and no clear reversible cause at the time.

My nurses filed a critical incident report for completely unrelated reasons.

The ICU attending now looking after her tagged in and said “peri-intubation arrest is incredibly rare, and the medical management of this case should be examined.”

I know for a fact that this ICU sees mostly stable post surgical and post stroke patients and my friend who has been a nurse there for a year said she has never seen a crash intubation, let alone one led by this doc.

I also know that his base specialty is anesthesia.

I replied, “happy to discuss, bearing in mind that the ICU context and the ER ‘first 15 minutes’ context are radically different.”

I acknowledge that peri-intubation arrest is not super common, but neither does it imply poor management, especially in an undifferentiated patient where we don’t even know the underlying etiology.

[u/dunknasty464]

I have no comments on this case specifically (since I was not there and don’t know full details).

However, a 10 second open evidence review indicates:

The incidence of peri-intubation cardiac arrest in emergency medicine and critical care patients ranges from approximately 1% to 3% depending on the clinical setting and patient population.

In the emergency department, large multicenter registry data report an incidence of 1.0% (95% CI 0.9–1.2%) for peri-intubation cardiac arrest, defined as occurring during or shortly after intubation in non-arrest patients. Other ED-based studies report similar rates, with incidences of 1.7% and 1.8%. In the intensive care unit, the incidence is slightly higher, with multicenter cohort studies reporting 2.7%. A systematic review and meta-analysis found a pooled incidence of 2% (95% CI 1–3.5%) for peri-intubation cardiac arrest across critically ill patients intubated outside the operating room or post-anesthesia care unit.[1][2][3][4][5]

These events are associated with significant morbidity and mortality, and the risk is increased in patients with pre-intubation hypotension, hypoxemia, or shock.[1][4][2][3][6] The incidence of other major peri-intubation adverse events, such as cardiovascular collapse (hypotension requiring intervention), is higher, occurring in 18–43% of cases, but true cardiac arrest remains less common.[7][8][5][9][10]

In summary, the incidence of peri-intubation cardiac arrest is approximately 1–3% in emergency and critical care settings.[5][1][4][2][3][6]

References

1. Peri-Intubation Cardiac Arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) Study. April MD, Arana A, Reynolds JC, et al. Resuscitation. 2021;162:403-411. doi:10.1016/j.resuscitation.2021.02.039.
2. Risk Factors Associated With Peri-Intubation Cardiac Arrest in the Emergency Department. Yang TH, Chen KF, Gao SY, Lin CC. The American Journal of Emergency Medicine. 2022;58:229-234. doi:10.1016/j.ajem.2022.06.013.
3. Factors Associated With the Occurrence of Cardiac Arrest After Emergency Tracheal Intubation in the Emergency Department. Kim WY, Kwak MK, Ko BS, et al. PloS One. 2014;9(11):e112779. doi:10.1371/journal.pone.0112779.
4. Cardiac Arrest and Mortality Related to Intubation Procedure in Critically Ill Adult Patients: A Multicenter Cohort Study. De Jong A, Rolle A, Molinari N, et al. Critical Care Medicine. 2018;46(4):532-539. doi:10.1097/CCM.0000000000002925.
5. Prevalence of Peri-Intubation Major Adverse Events Among Critically Ill Patients: A Systematic Review and Meta Analysis. Downing J, Yardi I, Ren C, et al. The American Journal of Emergency Medicine. 2023;71:200-216. doi:10.1016/j.ajem.2023.06.046.
6. Incidence and Factors Associated With Cardiac Arrest Complicating Emergency Airway Management. Heffner AC, Swords DS, Neale MN, Jones AE. Resuscitation. 2013;84(11):1500-4. doi:10.1016/j.resuscitation.2013.07.022.
7. Peri-Intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights From the INTUBE Study. Russotto V, Tassistro E, Myatra SN, et al. American Journal of Respiratory and Critical Care Medicine. 2022;206(4):449-458. doi:10.1164/rccm.202111-2575OC.
8. Intubation Practices and Adverse Peri-Intubation Events in Critically Ill Patients From 29 Countries. Russotto V, Myatra SN, Laffey JG, et al. Jama. 2021;325(12):1164-1172. doi:10.1001/jama.2021.1727.
9. Tracheal Intubation in the Critically Ill Patient. Russotto V, Rahmani LS, Parotto M, Bellani G, Laffey JG. European Journal of Anaesthesiology. 2022;39(5):463-472. doi:10.1097/EJA.0000000000001627.
10. Incidence of and Risk Factors for Severe Cardiovascular Collapse After Endotracheal Intubation in the ICU: A Multicenter Observational Study. Perbet S, De Jong A, Delmas J, et al. Critical Care (London, England). 2015;19:257. doi:10.1186/s13054-015-0975-9.

[u/dunknasty464 → u/dunknasty464]

In contrast, regarding elective OR intubations in stable patients for anesthesia, Open Evidence indicates:

The incidence of peri-intubation cardiac arrest in stable patients undergoing elective intubation for anesthesia is extremely low. Large perioperative registries and audits focused on the operating room setting, where patients are typically optimized and elective cases predominate, consistently report anesthesia-related cardiac arrest rates between 0.6 and 0.74 per 10,000 anesthetics (approximately 1 in 13,000 to 1 in 16,000 cases). The 7th National Audit Project of the Royal College of Anaesthetists found an overall perioperative cardiac arrest incidence of 3 per 10,000 anesthetics, but the majority of these events occurred in patients with significant comorbidities, higher ASA physical status, or during urgent/emergency procedures; the rate in healthy, stable, elective cases is even lower.[1][2][3][4]

Most anesthesia-related cardiac arrests in the elective setting are attributable to airway or respiratory complications and medication-related events, with risk factors including higher ASA status, pre-existing cardiac disease, and the use of vasopressors. In summary, for stable patients undergoing elective intubation for anesthesia, the incidence of peri-intubation cardiac arrest is less than 1 per 10,000 cases.[2][3][5][1]

References

1. Incidence and Risk Factors of Anaesthesia-Related Perioperative Cardiac Arrest: A 6-Year Observational Study From a Tertiary Care University Hospital. Hohn A, Machatschek JN, Franklin J, Padosch SA. European Journal of Anaesthesiology. 2018;35(4):266-272. doi:10.1097/EJA.0000000000000685.
2. Perioperative Cardiac Arrests - A Subanalysis of the Anesthesia -Related Cardiac Arrests and Associated Mortality. Sobreira-Fernandes D, Teixeira L, Lemos TS, et al. Journal of Clinical Anesthesia. 2018;50:78-90. doi:10.1016/j.jclinane.2018.06.005.
3. Anesthesia-Related Cardiac Arrest. Ellis SJ, Newland MC, Simonson JA, et al. Anesthesiology. 2014;120(4):829-38. doi:10.1097/ALN.0000000000000153.
4. Peri-Operative Cardiac Arrest: Epidemiology and Clinical Features of Patients Analysed in the 7th National Audit Project of the Royal College of Anaesthetists. Armstrong RA, Soar J, Kane AD, et al. Anaesthesia. 2024;79(1):18-30. doi:10.1111/anae.16156.
5. Airway and Respiratory Complications During Anaesthesia and Associated With Peri-Operative Cardiac Arrest as Reported to the 7th National Audit Project of the Royal College of Anaesthetists. Cook TM, Oglesby F, Kane AD, et al. Anaesthesia. 2024;79(4):368-379. doi:10.1111/anae.16187.

[u/Ineffaboble → u/dunknasty464]

"the majority of these events occurred ... during urgent/emergency procedures"

This right here. "ED" doesn't stand for "Elective Department."

[u/dunknasty464 → u/Ineffaboble]

I wish we could communicate this fact professionally to some of our more frequent fliers, however..

I would be open to criticism if I was you OP. You may have done everything right. An attending in residency once told me, that “If I don’t have ten minutes to collect my thoughts, I’m not performing standard resuscitation, I’m preparing for ACLS care.”

Again, without any other details regarding the case, the one thing I would for sure do before any attempt at passing a tube in a patient I can’t get pre-intubation sats above 65% would be to have someone else call for help as I proceed if emergently indicated (ED colleagues, ICU, anesthesia — whoever I can request within my system). This is not always an option at some places. Again, you may have done everything right, and this might be BS — but we can always try to do better for our patients, and it sounds like you worked diligently to give this patient the best possible outcome in what was already a peri-arrest patient.