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/lipkissy]

I think it’s impossible to speculate without further details of the case, and it’s not unreasonable to look into these events further from a QI perspective.

Was there an attempt to bag the patient back up with PEEP before attempting intubation? Was the patient apneic during laryngoscopy? Were induction agents used?

Sometimes it’s unavoidable, sometimes there are areas of improvement. Flash pulmonary edema is usually easily treatable with bag valve mask and positive pressure, which can buy time for a more controlled intubation.

[u/Ineffaboble → u/lipkissy]

I'm always happy to reflect. It was the clear implication (as a middle aged visibly queer woman who works nights in a downtown ER I'm no snowflake) that it HAD to be the result of a clinical error that chafed. Reflection and debrief? Sure. Critical incident review? That felt misplaced.

[u/hilltopj → u/Ineffaboble]

I had a decompensated heart failure who died within 24 hours of my admitting him. He was sick but I didn't think THAT sick. I was worried I missed something or mismanaged somehow so I sent the case and a quick explanation to my ED director. He in turn sent it on to the partner who does our M&M presentations. It got reviewed by our group, feedback and discussion happened; it was all anonymous and informative. My group is super supportive with these situations, if you feel yours is too I'd encourage you to self submit for review.