Should We Stop Using Propofol for RSI? | The INTUBE Study

Written by Aaron Lacy

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Patients who suffer from peri-intubation cardiovascular instability and collapse have an increased risk of mortality. Propofol was significantly associated with increased risk of peri-intubation instability and collapse.

Why does this matter?
Airway management begins as soon as a threatened airway is identified, and management includes peri-intubation resuscitation and selection of induction and paralytic agents. The more we know about modifiable risk factors to prevent peri-intubation cardiovascular instability and collapse, the better chance we have of improving patient outcomes.

That’s a nice blood pressure you got there. It’d be a shame if I pushed some propofol…
2,760 patients deemed critically ill from 197 clinical sites underwent analysis to identify modifiable variables associated with peri-intubation cardiovascular instability (SBP <65 mm Hg, new vasopressor requirement, fluid bolus requirement) and collapse and their associated outcomes. If a patient suffered from peri-intubation cardiovascular instability/collapse there was a higher risk of death while in the ICU (aOR 2.47; 95%CI 1.72-3.55) and at 28 days (aOR 2.52; 95% CI, 1.72-3.68)

While other studies in both children and adults show that pre-intubation hypotension and hypoxia can lead to increased risk of cardiac arrest, this study did not show an association with either low SBP or SpO2. It did show that patients who were intubated with propofol (n = 1,142) were found to have a significantly higher risk of peri-intubation instability/collapse (OR 1.28, 95%CI 1.05-1.57).

I was surprised to see how often propofol was chosen for induction in this study. The authors sought to identify modifiable risk factors for peri-intubation problems, and while I try to get the patient’s shock index to a favorable value with resuscitation it can sometimes be challenging. One thing that is not challenging is swapping your induction agent; I will continue to use etomidate and ketamine for my induction agents of choice.

Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study. Am J Respir Crit Care Med. 2022 Aug 15;206(4):449-458. doi: 10.1164/rccm.202111-2575OC.

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