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Incidence of post-intubation hemodynamic instability associated with emergent endotracheal intubations: a systematic review


The development of hemodynamic instability following emergent endotracheal intubation and the initiation of positive pressure ventilation is a potentially life-threatening adverse event. Unfortunately, the incidence of post-intubation hemodynamic instability (PIHI) is relatively unknown. The objective of this study is to estimate the risk of PIHI in adult patients who require emergent intubation and to identify factors contributing to the likelihood of this adverse event.


This is a systematic review of published adult, inhospital studies of emergent endotracheal intubation. A systematic search of Medline (1950 to November 2008) and relevant bibliographies was completed. No restrictions were placed on the language of publication, patient diagnosis, indication for intubation, or intubation method employed. One author independently reviewed all citations, and two authors reviewed all candidate articles during the process of final selection. Data were independently retrieved on a standardized data abstraction form by two authors. Random-effects meta-analysis was used to estimate the pooled prevalence of PIHI across studies.


A total of 22 relevant studies were identified and included in our analysis. One randomized controlled trial and 21 observational studies met the eligibility criteria. Sample sizes ranged from 33 to 2,833 patients (median, 214). The prevalence of post-intubation hypotension ranged from 0% to 39%, with a random-effects, pooled estimate of 8.5% (95% CI, 4.8% to 14.5%). Studies that defined PIHI with a temporal relationship between blood pressure reduction and intubation had a PIHI prevalence of 13.9% (95% CI, 8.8% to 21.2%) compared with a prevalence of 5.0% (95% CI, 1.6% to 15.0%) in studies that did not. Heterogeneity between studies limits conclusions on the effect of indication for intubation, intubator experience, medications utilized to facilitate intubation, and management strategies used for PIHI.


Post-intubation hemodynamic instability occurs commonly after emergent intubations. Efforts are required to identify risk factors, and potential preventative and therapeutic interventions for PIHI.

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Green, R., Hutton, B., McIntyre, L. et al. Incidence of post-intubation hemodynamic instability associated with emergent endotracheal intubations: a systematic review. Crit Care 13 (Suppl 1), P14 (2009).

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