Optimize Patient Before Intubation to Reduce ICU Complications

Oxygenation and hemodynamic stabilization before intubation could help reduce complications for patients in the ICU, according to a recent study.

Procedurally related complications from airway management occurred commonly in the ICU, despite first-attempt success, researchers found.

“We’re trying to address the risk factors for these complications prior to intubation,” said Thomas Navarro, MD, of the University of Arizona Health Sciences Center, in Tucson. Dr. Navarro presented the research during the 2016 annual meeting of the Society for Airway Management.

“If we can wait 10 to 15 minutes prior to intubation to optimize a patient and reduce the complication rate, we should do it,” he said.

The observational study investigated 905 video laryngoscopy intubations performed in the University of Arizona’s medical ICU between Jan. 1, 2012, and Jan. 1, 2016. Of these, 739 (82%) were successful intubations on first attempt, and 146 (20%) patients experienced at least one complication.

Despite first-attempt success, difficult airway characteristics were associated with at least one complication, including:

• hypoxemia
• hemodynamic instability
• airway edema
• vomit in the airway

“Limiting laryngoscopic attempts is the goal of airway management because of the association with reduced risk of complications,” he said. “However, there are still complications that occur despite first-attempt success.”

Patient demographics showed a median age of 60 years, and men experienced more complications. Among the procedures, rapid sequence intubation was used in 80% of cases, and sedation only was used in 16%. First-attempt success was highest during operators’ fourth and fifth postgraduate years.

First-Pass Success Not Good Enough

“As a third-year resident interested in critical care, I have one foot moving toward more training and the other trying to teach medical students,” Dr. Navarro said. “This model helps me to do that because we must talk about improving the patient’s physiologic status prior to intubation.”

Airway characteristics such as vomit in the airway can be late presenters, he added, which medical students should be aware of and discuss strategies before intubating patients.

“When aspiration has already occurred, I’m two to four minutes behind already,” Dr. Navarro said. “I can suction as best I can, but I’m already behind, so the learning moment is to address and optimize the patient.”

The study also helped Dr. Navarro create a base rate for how to oxygenate and stabilize a patient. If possible, medical students can reduce edema and clean vomit before intubation.

“This suggests that a goal of first-pass success is not good enough because we can still have a complication,” said John C. Sakles, MD, of the University of Arizona, a co-author of the study and moderator of the poster presentations. Dr. Sakles recalled that 20 years ago during his training, few patients were physiologically optimized before intubation.

“The mantra back then was the ‘ABCs’ for resuscitation of the critically ill, where the airway was secured before any other clinical issues were addressed,” he said. Breathing and compressions then followed.

Current thinking has changed, and the new mantra is “CAB,” with deprioritization of airway control, Dr. Sakles added.

“What we are seeing now is a greater emphasis on physiologic optimization prior to airway control, which will likely result in improved outcomes during emergency intubation.”