Endotracheal intubation in critically ill patients, practices, complications and factors associated with post intubation hypotension: a study in National Hospital Sri Lanka

Context

Intubation in critical care setting is common and associated complication rates are high, up to 40%. Complication rates differ from intensive care unit (ICU) to ICU as their guidelines and practices are different. Post induction hypotension (PIH) is associated with increased mortality, morbidity and length of ICU stay.

Objectives

Primary objective was to describe the practices, common induction agents, neuromuscular blocking agents used for intubation and to identify the common complications following intubation in critically ill patients in National Hospital Sri Lanka (NHSL). The secondary objective was to identify factors associated with post intubation hypotension in critically ill patients.

Methodology

Descriptive cross -sectional study design with analytical component. Critically ill patients who were subjected to intubation outside theatre were the target population. Study was conducted in all ICUs, A&Es and ward settings in NHSL. Data entered to IBM SPSS 20 version. Basic descriptive statistical analysis was done, and data was summarized using frequency percentages. In the analytical component, univariate analysis was performed on variables to find statistically significant risk-factors for development of PIH. Statistically significant risk factors were subjected to multivariate analysis. Statistical associations were studied using regression co-efficient and chi-square test. P value <0.05 was taken as significant.

Results

Data from 150 intubations were analysed. Pre intubation cardiovascular (52%) and respiratory support (60%) was high. Majority (60%) of intubations of critically ill was performed during daytime and in the ICUs (68%). Commonly used induction agent was midazolam (58%) and neuromuscular blocking agent (NMB) was suxamethonium (84%). Supplemental fentanyl was used in 76% of cases. No failed intubation was recorded and 68% of time intubation was successful in the first attempt. Mechanical complications were low (6%) each for oesophageal intubation and aspiration and regurgitation. Post intubation hypoxaemia was common (50%). PIH was calculated as 26% according to definition (New or increased requirement of vasopressors within 60mins of intubation). After multivariate analysis, propofol induction (OR 17.38, P value = 0.000), post intubation hypoxaemia (OR 3.3, P value = 0.033), post intubation mechanical complications (OR 3.8, P value = 0.000), suxamethonium (OR 0.09, p value = 0.003), pre intubation airway support (OR 0.012, P value = 0.000), pre intubation cardiovascular support (OR 0.025, P value = 0.000, have shown association with PIH.