An overview of vasopressors for post-intubation hypotension in critically ill adult patients: the lay of the land

Endotracheal intubation is a critical procedure in managing critically ill patients, including those in the emergency department (ED), but a significant risk of post-intubation hypotension accompanies it. Hypotension can occur due to the vasodilatory and negative inotropic effects of induction drugs, as well as the decreased preload associated with a change to positive-pressure ventilation. In this Canadian Journal of Emergency Medicine issue, Marks and colleagues report the findings of their PRISMA-adherent scoping review that identified studies reporting hemodynamic data in critically ill, non-cardiac arrest patients undergoing emergent endotracheal intubation. They provide a literature overview on the incidence of post-intubation hypotension in critically ill adult patients who did and did not receive vasopressors [1]. The authors found that hypotension was common, occurring in 22.2% of patients across all studies and 34.3% in studies where authors explicitly reported vasopressor administration pre-intubation. Although rates of hypotension were higher in studies reporting pre-intubation vasopressor use, these studies had lower in-hospital mortality [1]. One-hour mortality of patients across all studies and within the pre-intubation 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 [1]. The authors interpret the higher post-intubation hypotension incidence in studies reporting pre-intubation vasopressor administration as likely indicating that patients receiving vasopressors had more severe illnesses and that the observed outcomes are more attributable to the underlying condition than to vasopressor use [1].