title: Vasopressor use as a surrogate for post-intubation hemodynamic instability is associated with in-hospital and 90-day mortality: a retrospective cohort study.
abstract: BACKGROUND
  Evidence is lacking for what defines post-intubation hypotension in the intensive care unit (ICU). If a valid definition could be used, the potential exists to evaluate possible risk factors and thereby improve post-intubation. Thus, our objectives were to arrive at the best surrogate for post-intubation hypotension that accurately predicts both in-hospital and 90-day mortality in a population of ICU patients and to report mortality rates between the exposed and unexposed cohorts.
  
  
  METHODS
  We conducted a retrospective cohort study of emergent endotracheal intubations in a medical-surgical ICU from January 1, 2010 to December 31, 2011 to evaluate surrogates for post-intubation hypotension that would predict in-hospital and 90-day mortality followed by an analysis of exposed versus unexposed using our best surrogate. Patients were ≥18 years of age, underwent emergent intubation during their first ICU admission, and did not meet any of the surrogates 60 min pre-intubation.
  
  
  RESULTS
  The six surrogates evaluated 60 min post-intubation were those with any systolic blood pressures ≤90 mmHg, any mean arterial pressures ≤65 mmHg, reduction in median systolic blood pressures of ≥20%, any vasopressor administration, any non-sinus rhythm and, fluid administration of ≥30 ml/kg. A total of 147 patients were included. Of the six surrogates, only the administration of any vasopressor 60 min post-intubation remained significant for mortality. Twenty-nine patients were then labeled as hemodynamically unstable and compared to the 118 patients labeled as hemodynamically stable. After adjusting for confounders, the hemodynamically unstable group had a significantly higher in-hospital and 90-day mortality [OR (95% CI); 3.84 (1.31-11.57) (p value = 0.01) and 2.37 (1.18-4.61) (p-value = 0.02)].
  
  
  CONCLUSIONS
  Emergently intubated patients manifesting hemodynamic instability after but not before intubation, as measured by vasoactive administration 60 min post-intubation, have a higher association with in-hospital and 90-day mortality.
authors.affiliation: Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. smischney.nathan@mayo.edu.|Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. smischney.nathan@mayo.edu.
authors.forename: Nathan J
authors.initials: NJ
authors.lastname: Smischney
authors.affiliation: Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. demirci.onur@mayo.edu.
authors.forename: Onur
authors.initials: O
authors.lastname: Demirci
authors.affiliation: Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. ricter.bryce@mayo.edu.
authors.forename: Bryce D
authors.initials: BD
authors.lastname: Ricter
authors.affiliation: Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. hoeft.christina@mayo.edu.
authors.forename: Christina C
authors.initials: CC
authors.lastname: Hoeft
authors.affiliation: Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. johnson.lisa2@mayo.edu.
authors.forename: Lisa M
authors.initials: LM
authors.lastname: Johnson
authors.affiliation: Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. ansar.shejan@mayo.edu.
authors.forename: Shejan
authors.initials: S
authors.lastname: Ansar
authors.affiliation: Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA. kashyap.rahul@mayo.edu.
authors.forename: Rahul
authors.initials: R
authors.lastname: Kashyap
mesh_terms: D006439:Hemodynamics; D017052:Hospital Mortality; D006801:Humans; D007442:Intubation, Intratracheal / Q000401:mortality*; D012189:Retrospective Studies; D016019:Survival Analysis; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*
chemical_list: D014662:Vasoconstrictor Agents