Abstract
Endotracheal intubation in the ICU is a high-risk procedure, resulting in significant morbidity and mortality. Up to 40% of cases are associated with marked hypoxemia or hypotension. The ICU patient is physiologically very different from the usual patient who undergoes intubation in the operating room, and different intubation techniques should be considered. The common operating room practice of sedation and neuromuscular blockade to facilitate intubation may carry significant risk in the ICU patient with a marked oxygenation abnormality, particularly when performed by the non-expert. Preoxygenation is largely ineffective in these patients and oxygen desaturation occurs rapidly on induction of anesthesia, limiting the time available to secure the airway. The ICU environment is less favorable for complex airway management than the operating room, given the frequent lack of availability of additional equipment or additional expert staff. ICU intubations are frequently carried out by trainees, with a lesser degree of airway experience. Even in the presence of a non-concerning airway assessment, these patients are optimally managed as a difficult airway, utilizing an awake approach. Endotracheal intubation may be achieved by awake direct laryngoscopy in the sick ICU patient whose level of consciousness may be reduced by sepsis, hypercapnia or hypoxemia. As the patient’s spontaneous respiratory efforts are not depressed by the administration of drugs, additional time is available to obtain equipment and expertise in the event of failure to secure the airway. ICU intubation complications should be tracked as part of the ICU quality improvement process.
Highlights
Endotracheal intubation in the ICU is a high-risk procedure, resulting in significant morbidity and mortality
The ICU intubation usually occurs in an unstable patient often with a period of time to allow for evaluation and planning, and in an environment not always ideally suited to airway management
A significant proportion of ICU intubations are performed by relatively junior trainees, with or without supervision [1, 3, 5]
Summary
Endotracheal intubation in the ICU is a high-risk procedure, resulting in significant morbidity and mortality. The ICU intubation usually occurs in an unstable patient often with a period of time (albeit sometimes brief ) to allow for evaluation and planning, and in an environment not always ideally suited to airway management. Airway management guidelines developed for anesthesia have been applied to the ICU environment, the ICU patient is very different physiologically, and induction of anesthesia with resultant apnea is potentially harmful in this patient group.
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