The use of vasopressors to reduce post-intubation hypotension in critically ill adult patients undergoing emergent endotracheal intubation: a scoping review.

Abstract

Patients requiring emergent endotracheal intubation are at higher risk of post-intubation hypotension due to altered physiology in critical illness. Post-intubation hypotension increases mortality and hospital length of stay, however, the impact of vasopressors on its incidence and outcomes is not known. This scoping review identified studies reporting hemodynamic data in patients undergoing emergent intubation to provide a literature overview on post-intubation hypotension in cohorts that did and did not receive vasopressors. A systematic search of CINAHL, Cochrane, EMBASE and PubMed-Medline was performed from database inception until September 28, 2023. Two independent reviewers completed the title and abstract screen, full text review and data extraction per PRISMA guidelines. Studies including patients < 18years or intubations during cardiac arrest were excluded. Primary outcome was the presence of hypotension within 30min of emergent intubation. Secondary outcomes included mortality at 1 h and in-hospital. The systematic search yielded 13,126 articles, with 61 selected for final inclusion. There were 24,547 patients with a mean age of 57.2years and a slight male predominance (63.8%). Respiratory failure was the most common intubation indication. Across 18 studies reporting on vasopressor use prior to intubation, 1171/7085 patients received vasopressors pre-intubation. Post-intubation hypotension occurred in 22.2% of patients across all studies, and in 34.3% of patients in studies where vasopressor administration pre-intubation was specifically reported. One-hour mortality of patients across all studies and within the vasopressor use studies was 1.2% and 1.6%, respectively. In-hospital mortality across studies was 21.5%, and 13.1% in studies which reported on vasopressor use pre-intubation. Patients requiring emergent intubation have a high rate of post-intubation hypotension and in-hospital mortality. While there is an intuitive rationale for the use of vasopressors during emergent intubation, current evidence is limited to support a definitive change in clinical practice at this time.