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/irelli]

If you've seen several just from rapids in a year, then people probably are being mismanaged

The guy in the OP sounds like an asshole, but there's some validity to it. Peri intubation arrests shouldn't be common at all.

The vast majority of the time they occur it's because people rushed to intubate before fully resuscitating. There's a few patients that are likely going to arrest no matter what you because of their baseline physiology, but if you give blood, start Levo, etc first, you're almost never going to have them arrest

A lot of times people just are so worried about the airway that they skip just bagging or using an LMA for 5-10 minutes while everything gets set up

Chastising people is wrong, but so is accepting them as common - I haven't personally seen one in 3 years of emergency medicine, and we intubate a shit ton of people

[u/RickOShay1313 → u/irelli]

We have a big hospital with sick patients. Our ED staff do the airways and peri-intubation management. I think they are pretty competent and some times you do everything right and it still goes south 🤷‍♂️ I work nights a lot so i see a lot of coded. But it’s not my area of expertise and sure, maybe they are fucking up in ways i don’t fully understand

[u/irelli → u/RickOShay1313]

It shouldn't be going south often though. If it is, people are likely under resuscitating. It happens all the time.

Like this patient here it sounds like needed DSI instead of RSI - they started the intubation with the patient hypoxemic and they went into respiratory arrest

[u/RickOShay1313 → u/irelli]

i wouldn’t say it’s going south “often”. There are several codes every night i’m on and most are smooth, but all it takes is 1% or so to add up to a lot of bad cases over time. Are you saying you never have had a peri-intubation arrest?

[u/irelli → u/RickOShay1313]

Not yet, no. I'm only 3 years in so I won't pretend my sample size is huge (though it's not tiny either) but no, I haven't yet. I've seen plenty in our QA process though

At the end of the day, it's either a circulation problem or a respiratory problem. The circulatory one is easy - blood/fluids and pressors if they're even remotely borderline from a blood pressure standpoint or have any reason to think they can't take the increase in intrathoracic pressure (pulmonary hypertension, etc). I empirically start levo in a shit ton of my intubations.

If it's a respiratory problem, just do DSI, like the case in the OP should have been. Easy to say in hindsight obviously, but you don't start intubating someone that has a saturation in the 60s, unless you can't ventilate. They're going to die every single time. If they can't ventilate, you're probably fucked no matter what, but that's a rare situation. People just never want to sit back, start them on ketamine and let the bipap do its thing for 5 minutes before intubating. Doesn't matter if they're altered and "can't tolerate" bipap when you're about to intubate

[u/RickOShay1313 → u/irelli]

Yes i agree with what you are saying but our ED docs are already doing all of that. There are cases where no amount of blood and fluid and pressers is going to fix circulatory collapse and there are cases of respiratory failure where immediate intubation is the only option.

[u/irelli → u/RickOShay1313]

... like? Because the case listed above is neither of those man.

There are exceedingly few scenarios where circulatory collapse can't be avoided. Pulmonary hypertension is the scariest it gets, and you can just run vaso + norepi peripherally if they're that borderline. No one that came in alive doesn't respond to multiple pressors.

Respiratory I agree there are a few, but they are exclusively situations where you can't ventilate. If you can ventilate, then you don't have an excuse for starting your intubation with their sats in the 60s.

And situations where we can't ventilate are exceedingly rare. They're the kind where the problem often becomes the intubation itself (massive GI bleeds, angioedema, anaphylaxis, etc).

... And no one would ever blame a bad outcome in those situations, because you genuinely can't wait. But that's not the situation in 99% of Peri-intubation arrests. It's people rushing in to intubate because the person is floundering and not taking the time to get their sats up and to start peripheral pressors. People very very rarely do DSI