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/jcmush]

Sick people arresting is extremely common. RSI can precipitate it but he was going to arrest in the next few minutes.

Every induction drug(even ketamine) can have adverse effects on haemodynamic stability.

The question is about pre-intubation optimisation and choice of induction technique. There is no right answer(though 200mg of propofol is the wrong answer). Even BiPAP can precipitate an arrest(if the circulation can’t handle the PEEP) and vasopressors, including adrenaline, can have unexpected consequences with sick hearts.

In summary the ICU doc is wrong(but probably can’t be persuaded of that fact).

The case is great to discuss with your colleagues. You’ll get reassurance about your management and it’s interesting how many ways there are of dealing with the same problem.

My recipe:

1 - preintubation art line if it won’t delay things 2 - oxygenate via Mapleson C circuit(PEEP and FiO2 1.0) 3 - bolus adrenaline (100mcg aliquots) if hypotensive 4 - ketamine(0.5 mg/kg) and roc 5 - adrenaline(100-300 mcg depending on gut feeling) 6 - tube(Video laryngoscope) then high PEEP, high insp pressure, FiO2 1.0

I’d have pads on and a team member with a finger on the pulse ready to perform CPR.

[u/Ineffaboble → u/jcmush]

Thanks. I almost NEVER intubate with propofol.

[u/jcmush → u/Ineffaboble]

It’s good for an ASA 1 elective daycase. We don’t deal with many of those!