Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Mikita Fuchita, MD; Jack Pattee, PhD; Derek W. Russell, MD; Brian E. Driver, MD; Matthew E. Prekker, MD, MPH; Christopher R. Barnes, MD; Joseph M. Brewer, DO; Kevin C. Doerschug, MD; John P. Gaillard, MD; Sheetal Gandotra, MD; Shekhar Ghamande, MD; Kevin W. Gibbs, MD; Christopher G. Hughes, MD, MS; David R. Janz, MD, MSc; Akram Khan, MD; Steven H. Mitchell, MD; David B. Page, MD; Todd W. Rice, MD, MSc; Wesley H. Self, MD, MPH; Lane M. Smith, MD, PhD; Susan B. Stempek, PA-C, MBA, MMSc; Stacy A. Trent, MD, MPH; Derek J. Vonderhaar, MD; Jason R. West, MD; Micah R. Whitson, MD; Kayla Williamson, MS; Matthew W. Semler, MD, MSc; Jonathan D. Casey, MD, MSc; Adit A. Ginde, MD, MPH; for the Pragmatic Critical Care Research Group

doi:10.1097/CCE.0000000000000946

Critical Care Explorations (Jul 2023)

Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials

Mikita Fuchita, MD,
Jack Pattee, PhD,
Derek W. Russell, MD,
Brian E. Driver, MD,
Matthew E. Prekker, MD, MPH,
Christopher R. Barnes, MD,
Joseph M. Brewer, DO,
Kevin C. Doerschug, MD,
John P. Gaillard, MD,
Sheetal Gandotra, MD,
Shekhar Ghamande, MD,
Kevin W. Gibbs, MD,
Christopher G. Hughes, MD, MS,
David R. Janz, MD, MSc,
Akram Khan, MD,
Steven H. Mitchell, MD,
David B. Page, MD,
Todd W. Rice, MD, MSc,
Wesley H. Self, MD, MPH,
Lane M. Smith, MD, PhD,
Susan B. Stempek, PA-C, MBA, MMSc,
Stacy A. Trent, MD, MPH,
Derek J. Vonderhaar, MD,
Jason R. West, MD,
Micah R. Whitson, MD,
Kayla Williamson, MS,
Matthew W. Semler, MD, MSc,
Jonathan D. Casey, MD, MSc,
Adit A. Ginde, MD, MPH,
for the Pragmatic Critical Care Research Group

Affiliations

Mikita Fuchita, MD: 1 Department of Anesthesiology, Division of Critical Care, University of Colorado Anschutz Medical Campus, Aurora, CO.
Jack Pattee, PhD: 2 Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO.
Derek W. Russell, MD: 3 Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL.
Brian E. Driver, MD: 5 Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
Matthew E. Prekker, MD, MPH: 5 Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
Christopher R. Barnes, MD: 7 Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.
Joseph M. Brewer, DO: 8 Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS.
Kevin C. Doerschug, MD: 9 Department of Internal Medicine, University of Iowa, Iowa City, IA.
John P. Gaillard, MD: 10 Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
Sheetal Gandotra, MD: 3 Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL.
Shekhar Ghamande, MD: 12 Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Baylor Scott & White Medical Center, Temple, TX.
Kevin W. Gibbs, MD: 13 Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, NC.
Christopher G. Hughes, MD, MS: 14 Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
David R. Janz, MD, MSc: 15 University Medical Center New Orleans, New Orleans, LA.
Akram Khan, MD: 17 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University School of Medicine, Portland, OR.
Steven H. Mitchell, MD: 18 Department of Emergency Medicine, University of Washington, Seattle, WA.
David B. Page, MD: 3 Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL.
Todd W. Rice, MD, MSc: 20 Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN.
Wesley H. Self, MD, MPH: 21 Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN.
Lane M. Smith, MD, PhD: 9 Department of Internal Medicine, University of Iowa, Iowa City, IA.
Susan B. Stempek, PA-C, MBA, MMSc: 23 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA.
Stacy A. Trent, MD, MPH: 24 Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
Derek J. Vonderhaar, MD: 26 Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, LA.
Jason R. West, MD: 27 Department of Emergency Medicine, NYC Health + Hospitals | Lincoln, Bronx, NY.
Micah R. Whitson, MD: 3 Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL.
Kayla Williamson, MS: 2 Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO.
Matthew W. Semler, MD, MSc: 20 Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN.
Jonathan D. Casey, MD, MSc: 20 Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN.
Adit A. Ginde, MD, MPH: 24 Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO.
for the Pragmatic Critical Care Research Group

DOI: https://doi.org/10.1097/CCE.0000000000000946
Journal volume & issue: Vol. 5, no. 7
p. e0946

Abstract

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OBJECTIVE:. Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN:. A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING:. Seven emergency departments and 17 ICUs across the United States. PATIENTS:. One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (–12 vs –11 mm Hg; p = 0.66). CONCLUSIONS:. The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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