Right ventricular dysfunction: a key predictor of post-intubation hypotension in the emergency department

Post-intubation hypotension (PIh) is a frequent complication following drug-assisted intubation, leading to increased morbidity, mortality, and healthcare costs. Pre-intubation hemodynamic factors, acid-base imbalances, and existing comorbidities, particularly right ventricular dysfunction, which is a lesser-known variable, have emerged as a critical predictor of PIh. Since RV systolic motion is predominantly longitudinal, TAPSE on POCUS provides a time-sensitive surrogate of RV function for high risk patients in the Emergency department.

Aim: The study aimed to list hemodynamic predictors and their correlation with easily executable POCUS and point-of-care echocardiography variables, which can impact emergency decision-making and optimal management in PIh. This prospective observational study was conducted in the Department of Emergency Medicine at Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India. 172 patients aged ≥ 18 years undergoing drug-assisted intubation were observed. Baseline demographics, clinical parameters, hemodynamic indices, and pre-intubation echocardiographic values (TAPSE, EPSS) were recorded. Shock index and modified shock index were calculated. Point-of-care ultrasound (POCUS) assessed left and right ventricular function. PIh within 30 min was defined as SBP [Formula: see text] 90mmHg, ≥ 20% fall in SBP, MAP < 65mmHg or new vasopressor initiation. Associations were tested with logistic regression. TAPSE discrimination was obtained with ROC analysis and Youden's Index.

Of the 172 patients, 71 (41.2%) developed PIh. Patients with obstructive lung disease (59.3%, p = 0.039) and sepsis (66.7%) were significantly more likely to experience PIh. TAPSE values were significantly lower in those with PIh (17.66 ± 2.45 mm vs. 18.54 ± 2.15 mm, p = 0.014). The multivariate logistic regression revealed TAPSE as an independent predictor of PIh (OR = 0.81, 95% CI = 0.69-0.95, p = 0.009). ROC analysis of TAPSE showed moderate predictive power (AUC 0.584, 95% CI 0.497-0.672), with a cut-off of 17.6 mm (sensitivity 85.1% and specificity 29.6%).

TAPSE measured pre-intubation emerged as a reliable predictor of post-intubation hypotension. Incorporating a rapid assessment of right ventricular function using POCUS into the airway management algorithm provides valuable insights in identifying patients at higher risk of PIh.