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Objective: Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation. Methods: A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation. Results: Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients' pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients' risk of hypotension. Conclusions: A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients. Study registration: Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101. [ABSTRACT FROM AUTHOR]

The discovery and utilization of volatile anesthetics has significantly transformed surgical practices since their inception in the mid-19th century. Recently, a paradigm shift is observed as volatile anesthetics extend beyond traditional confines of the operating theatres, finding diverse applications in intensive care settings. In the dynamic landscape of intensive care, volatile anesthetics emerge as a promising avenue for addressing complex sedation requirements, managing refractory lung pathologies including acute respiratory distress syndrome and status asthmaticus, conditions of high sedative requirements including burns, high opioid or alcohol use and neurological conditions such as status epilepticus. Volatile anesthetics can be administered through either inhaled route via anesthetic machines/devices or through extracorporeal membrane oxygenation circuitry, providing intensivists with multiple options to tailor therapy. Furthermore, their unique pharmacokinetic profiles render them titratable and empower clinicians to individualize management with heightened accuracy, mitigating risks associated with conventional sedation modalities. Despite the amounting enthusiasm for the use of these therapies, barriers to widespread utilization include expanding equipment availability, staff familiarity and training of safe use. This article delves into the realm of applying inhaled volatile anesthetics in the intensive care unit through discussing their pharmacology, administration considerations in intensive care settings, complication considerations, and listing indications and evidence of the use of volatile anesthetics in the critically ill patient population., Competing Interests: Conflict-of-interest statement: All authors declare no conflicts of interest., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Endotracheal intubation is frequently performed in the intensive care unit (ICU). It can be life-saving for many patients who present with acute respiratory distress. However, it is equally associated with complications that may lead to unwanted effects in this patient population. According to the literature, the rate of complications associated with endotracheal intubation is much higher in an environment such as the ICU as compared to other, more controlled environments (i.e., operating room). Thus, the conduct of performing such a procedure needs to be accomplished with the utmost care. To facilitate establishment of the breathing tube, sedation is routinely administered. Given the tenuous hemodynamic status of the critically ill, etomidate was frequently chosen to blunt further decreases in blood pressure and/or heart rate. Recently however, reports have demonstrated a possible association with the use of etomidate for endotracheal intubation and mortality in the critically ill. In addition, this association seems to be predominantly in patients diagnosed with sepsis. As a result, some have advocated against the use of this medication in septic patients. Due to the negative associations identified with etomidate and mortality, several investigators have evaluated potential alternatives to this solution (e.g., ketamine and ketamine-propofol admixture). These studies have shown promise. However, despite the evidence against using etomidate for endotracheal intubation, other studies have demonstrated no such association. This leaves the critical care clinician with uncertainty regarding the best sedative to administer in this patient population. The following editorial discusses current evidence regarding etomidate use for endotracheal intubation and mortality. In particular, we highlight a recent article with the largest population to date that found no association between etomidate and mortality in the critically ill and illustrate important findings that the reader should be aware of regarding this article.

Background: The primary aim of this study was to determine the period prevalence of the single-syringe ketamine-propofol admixture used for sedation and induction among anesthesia providers during a 5-year period before and after educational sessions addressing barriers to its use. Secondary aims were to determine barriers to its use and address the most prevalent concerns through educational sessions., Material and Methods: Surveys were administered to certified and student registered nurse anesthetists, anesthesia residents, and anesthesiologists at Mayo Clinic Rochester, MN before and after educational sessions addressing common barriers. Identified barriers were addressed by oral and/or electronic presentations with identical content., Results: Pre-education period prevalence for sedation was 110 (43%) and 64 (25%) for induction. Identified barriers were uncertainty of benefit in 62 respondents (23%), mixed controlled substance disposal in 48 (18%), regulatory/institutional policies in 20 (7%), and compatibility in 9 (3%). Post-education period prevalence for sedation was 102 (44%), and induction 63 (27%). No concerns were noted in 72% of the post-education group verses 42% in the pre-education group (p<0.01). No concerns were reported in 51% of the electronic only education group verses 64% in the oral education group (p<0.01)., Conclusions: The period prevalence of "ketofol" was greater for sedation than induction. The period prevalence following education showed a slight increase in both sedation and induction use. There was a significant reduction in barriers following education, with oral presentations being more effective than electronic only. Period prevalence was increasing following education; however, allowing more time may have shown a significant practice change.

Background: Endotracheal intubation is a common procedure performed for critically ill patients that can have immediate life-threatening complications. Induction medications are routinely given to facilitate the procedure, but most of these medications are associated with hypotension. While etomidate is known for its neutral hemodynamic profile, it has been linked with increased mortality in septic patients and increased morbidity in trauma patients. Ketamine and propofol are effective anesthetics with counteracting cardiovascular profiles. No data are available about the use of this combination in critically ill patients undergoing endotracheal intubation., Case Report: We describe 6 cases in which the combination of ketamine and propofol ("ketofol") was used as an induction agent for endotracheal intubation in critically ill patients with a focus on hemodynamic outcomes. All patients received a neuromuscular blocker and fentanyl, while 5 patients received midazolam. We recorded mean arterial pressure (MAP) 1 minute before induction and 15 minutes after intubation with the combination. Of the 6 patients, 5 maintained a MAP ≥ 65 mmHg 15 minutes after intubation. One patient was on norepinephrine infusion with a MAP of 64 mmHg, and did not require an increase in the dose of the vasopressor 15 minutes after intubation. No hemodynamic complications were reported after any of the intubations., Conclusions: This case series describes the use of the "ketofol" combination as an induction agent for intubation in critically ill patients when hemodynamic stability is desired. Further research is needed to establish the safety of this combination and how it compares to other induction medications.