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/Zentensivism]

This doctor is a fool. It’s incredibly rare if you plan properly and provide appropriate care. I see peri-intubation instability and near arrest cases weekly. It’s the exact reason why we are taught to plan for those “HOP killers” downstairs and upstairs I’ll place an art line in those who are at risk and have push dose pressors in my pocket.

[u/Ineffaboble → u/Zentensivism]

Thanks and yeah what's galling is that I am probably way more conscious about the "physiologically difficult airway" than many ER docs I know (at least according to residents lol) and very focused on optimizing the patient's hemodynamics and preox -- in part because of a very scary peri-intubation arrest I witnessed in residency. I'm not a cowgirl (when I'm on the clock anyways)

[u/Zentensivism → u/Ineffaboble]

I was lucky to train in an environment where ED nurses knew how to setup arterial lines and attendings would even lay into trauma surgeons for aggressively pushing for intubation before getting appropriate access and level 1 infuser going for MTP or pressors. Even with this level of preparation we still saw quite a few periarrest cases, and that’s just the unfortunate progression of disease when presenting late.

Someone earlier asked about which push dose pressor. It really depends on the situation and suspected underlying medical conditions. If I’m suspecting primarily cardiogenic with a heart rate that can tolerate more beta agonism I will have both the 1000 mcg phenylephrine stick and a mixed 9:1 push dose epi, otherwise septic cases mostly just phenylephrine.

[u/Ineffaboble → u/Zentensivism]

Same here. In training we did a lot more "ICU in the ED" than I've ever seen as an attending where I now work. COVID, retirement of our most senior nursing staff, burnout, superabundant ICU interns and fellows -- now it's pretty rare for us to do any of that stuff in the ED. I do lots of rural locums though and I still meet teams that are comfortable doing all the ICU stuff. Myself I'm always down to put in an IJ, art line, whatever the patient needs, it's just a question of whether it's warranted given imminent transfer, plus nurse availability and comfort level.

[u/hilltopj → u/Ineffaboble]

Same. where I trained we did A LOT more ICU in the ED. when I got my first attending gig I found out the new ED monitors didn't even have art line connections. I was doing so many that now all the techs and nurses know how to set up and where to find the one transport monitor that still runs art lines.

The only unfortunate part of me doing more than a lot of my colleagues is that the IR and ICU docs have caught on. Now I get more pushback when I'm slammed and I think a patient is stable enough to get the procedure done outside of the ED.

[u/GPStephan → u/hilltopj]

Insert "suffering from success" meme.