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/medschoolloans123]

It’s not rare at all. I always have push dose epi at bedside for all my tubes because I’ve seen it happen so many times. Heck sometime I have peripheral levo ready to run.

It is not “incredibly rare” at all this person has no idea what they are talking about.

The number quoted in a lot of literate is up to 3%. That sounds low but that’s 3 out of every 100 tubes. That actually quite a bit.

[u/Ineffaboble → u/medschoolloans123]

For real. I know it's common and that's why I always resuscitate and optimize before I intubate. Going forward, I am going to reinforce that it's 3-5% of the time and that's where we truly save lives.

[u/medschoolloans123 → u/Ineffaboble]

Push dose Epi has saved my butt so many times during intubations. Even tubes where I was just intubating for airway protection have sometimes surprised me with post intubation hypotension. Always be prepared.

If you haven’t seen a lot of peri intubation hypotension/arrest you have not done enough tubes. Or all the tubes you have done have been on very stable patients.

[u/irelli → u/medschoolloans123]

I really don't agree with this. They might be hypotensive beforehand, but the goal should be to stabilize before you start. If they're hypotensive or even remotely borderline, why wait to start the levo or give epi until afterwards? Start the levo drip, then intubate.

Sick patients can still be stabilized before intubating. The only real time you should be having peri intubation arrests is for patients where the Airway itself is the concern (anaphylaxis, penetrating neck trauma) and you don't have time to optimize because you can't ventilate.

People love to rush into intubations. If you can ventilate, there is time.