Cardiopulmonary prognosis of prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy

doi:10.5847/wjem.j.1920-8642.2023.080

Abstract

Abstract:

BACKGROUND: It is controversial whether prophylactic endotracheal intubation (PEI) protects the airway before endoscopy in critically ill patients with upper gastrointestinal bleeding (UGIB). The study aimed to explore the predictive value of PEI for cardiopulmonary outcomes and identify high-risk patients with UGIB undergoing endoscopy.
METHODS: Patients undergoing endoscopy for UGIB were retrospectively enrolled in the eICU Collaborative Research Database (eICU-CRD). The composite cardiopulmonary outcomes included aspiration, pneumonia, pulmonary edema, shock or hypotension, cardiac arrest, myocardial infarction, and arrhythmia. The incidence of cardiopulmonary outcomes within 48 h after endoscopy was compared between the PEI and non-PEI groups. Logistic regression analyses and propensity score matching analyses were performed to estimate effects of PEI on cardiopulmonary outcomes. Moreover, restricted cubic spline plots were used to assess for any threshold effects in the association between baseline variables and risk of cardiopulmonary outcomes (yes/no) in the PEI group.
RESULTS: A total of 946 patients were divided into the PEI group (108/946, 11.4%) and the non-PEI group (838/946, 88.6%). After propensity score matching, the PEI group (n=50) had a higher incidence of cardiopulmonary outcomes (58.0% vs. 30.3%, P=0.001). PEI was a risk factor for cardiopulmonary outcomes after adjusting for confounders (odds ratio [OR] 3.176, 95% confidence interval [95% CI] 1.567-6.438, P=0.001). The subgroup analysis indicated the similar results. A shock index >0.77 was a predictor for cardiopulmonary outcomes in patients undergoing PEI (P=0.015). The probability of cardiopulmonary outcomes in the PEI group depended on the Charlson Comorbidity Index (OR 1.465, 95% CI 1.079-1.989, P=0.014) and shock index >0.77 (compared with shock index ≤0.77 [OR 2.981, 95% CI 1.186-7.492, P=0.020, AUC=0.764]).
CONCLUSION: PEI may be associated with cardiopulmonary outcomes in elderly and critically ill patients with UGIB undergoing endoscopy. Furthermore, a shock index greater than 0.77 could be used as a predictor of a worse prognosis in patients undergoing PEI.

Key words: Prophylactic endotracheal intubation, Upper gastrointestinal bleeding, Cardiopulmonary outcomes, eICU Collaborative Research Database

Yufang Lin, Fei’er Song, Weiyue Zeng, Yichi Han, Xiujuan Chen, Xuanhui Chen, Yu Ouyang, Xueke Zhou, Guoxiang Zou, Ruirui Wang, Huixian Li, Xin Li. Cardiopulmonary prognosis of prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy[J]. World Journal of Emergency Medicine, 2023, 14(5): 372-379.

Figures/Tables 6

Figure 1.

Table 1.

Baseline characteristics of the PEI group and the non-PEI group—crude and adjusted

Variables	Unmatched data			Matched data
Variables	PEI (n=108)	Non-PEI (n=838)	P-value	PEI (n=50)	Non-PEI (n=100)	P-value
Age, year	63.00 (52.00-74.00)	65.00 (53.00-76.00)	0.087^a	64.00 (56.75-74.25)	64.00 (56.75-76.00)	0.952^a
Male	63 (58.3)	494 (58.9)	0.902^a	28 (56.0)	50 (50.0)	0.488^a
BMI, kg/m²	28.30 (23.92-33.49)	26.83 (23.02-31.60)	0.168^a	28.41 (24.46-33.19)	26.81 (24.43-30.93)	0.195^a
Heart rate, beat/min	94.00 (79.25-107.25)	92.00 (82.00-104.00)	0.450^a	95.00 (77.00-111.00)	92.00 (80.25-104.75)	0.825^a
Systolic pressure, mmHg	113.00 (103.00-131.00)	119.00 (107.00-133.00)	0.029^a	114.50 (102.75-129.70)	119.00 (110.25-125.75)	0.472^a
Caucasian	76 (70.4)	646 (77.1)	0.353	34 (68.0)	76 (76.0)	0.716
Use of sedative during endoscopy	25 (23.1)	66 (7.9)	<0.001	13 (26.0)	27 (27.0)	0.896
Use of vasopressors before endoscopy	32 (29.6)	78 (9.3)	<0.001	10 (20.0)	13 (13.0)	0.262
Red blood cells infusion before endoscopy	68 (63.0)	442 (52.7)	0.045	30 (60.0)	43 (43.0)	0.050
APACHE Ⅳ score	79.50 (66.25-91.75)	54.00 (45.00-65.00)	<0.001^a	68.99±2.58	66.63±1.99	0.319^b
CCI <4	98 (90.7)	796 (95.0)	0.068	47 (94.0)	91 (91.0)	0.750
AIMS65 score	2.00 (2.00-3.00)	1.00 (1.00-2.00)	<0.001^a	2.00 (1.00-2.00)	1.00 (1.00-2.00)	0.529^a
Glasgow Coma Scale	12.00 (9.00-15.00)	15.00 (15.00-15.00)	<0.001^a	15.00 (15.00-15.00)	15.00 (14.25-15.00)	0.616^a
MELD score	11.26 (6.37-18.90)	7.58 (4.35-13.06)	0.001^a	10.46 (6.57-14.47)	11.13 (5.48-17.09)	0.739^a
Ongoing active hematemesis, agitation, or encephalopathy before endoscopy	25 (23.1)	238 (28.4)	0.251	11 (22.0)	36 (36.0)	0.081
INR	1.30 (1.20-1.67)	1.30 (1.10-1.40)	0.001^a	1.35 (1.19-1.50)	1.35 (1.10-1.63)	0.848^a
Total billirubin, mg/dL	0.80 (0.80-2.47)	0.80 (0.50-1.20)	<0.001^a	1.10 (0.67-1.30)	1.10 (0.50-1.87)	0.615^a
Creatinine, mg/dL	0.95 (0.77-1.34)	0.90 (0.71-1.27)	0.231^a	1.03 (0.83-1.33)	1.03 (0.80-1.94)	0.851^a
Hemoglobin, g/dL	8.80 (7.80-9.9)	8.60 (7.80-9.60)	0.226^a	9.14±0.27	8.72±0.17	0.168^b
History of cirrhosis	39 (36.1)	175 (20.9)	<0.001	15 (30.0)	34 (34.0)	0.622
History of heart disease ^a	16 (14.8)	204 (24.3)	0.027	9 (18.0)	21 (21.0)	0.665
History of lung disease ^b	17 (15.7)	159 (19.0)	0.416	10 (20.0)	20 (20.0)	1.000
Position of bleeding
Varices	26 (24.1)	119 (14.2)	0.007	11 (22.0)	14 (14.0)	0.215
Ulcer	17 (15.7)	98 (11.7)	0.226	6 (12.0)	13 (13.0)	0.862

Table 1.

Table 2.

Table 3.

Figure 2.

Figure 3.

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Outcomes	Unmatched data			Matched data
Outcomes	PEI (n=108)	Non-PEI (n=838)	P-value	PEI (n=50)	Non-PEI (n=100)	P-value
Cardiopulmonary outcomes	57 (52.8)	248 (29.6)	<0.001	29 (58.0)	30 (30.3)	0.001
Cardiac arrest	4 (3.7)	2 (0.2)	<0.001^a	3 (6.0)	0 (0.0)	0.010^c
Myocardial infarction	1 (0.9)	17 (2.0)	0.678^a	1 (2.0)	5 (5.0)	0.659^a
Arrhythmia	17 (15.7)	103 (12.3)	0.311	11 (22.0)	11 (11.0)	0.073
Shock/hypotension	45 (41.7)	146 (17.4)	<0.001	22 (44.0)	11 (11.0)	<0.001
Aspiration	1 (0.9)	7 (0.8)	1.000	1 (2.0)	1 (1.0)	1.000^a
Pneumonia	6 (5.6)	24 (2.9)	0.133	5 (10.0)	3 (3.0)	0.158^a
Pulmonary edema	5 (4.6)	1 (0.1)	<0.001^a	3 (6.0)	0 (0.0)	0.010^c
Post-endoscopy vasopressor use within 48 h	35 (32.4)	55 (6.6)	<0.001	11 (22.0)	10 (10.0)	0.046
Post-endoscopy antibacterial use within 48 h	28 (25.9)	131 (15.6)	0.007	16 (32.0)	25 (25.0)	0.364
Radiology within 48 h	16 (14.8)	85 (10.1)	0.139	7 (14.0)	8 (8.0)	0.248
Red blood cells infusion within 48 h	72 (66.7)	453 (54.1)	0.013	31 (62.0)	44 (44.0)	0.038
Hospital LOS, d	9.62 (5.42-16.41)	4.89 (3.11-8.06)	<0.001^b	9.71 (5.63-15.16)	5.50 (3.40-10.53)	0.001^b
ICU LOS, d	3.44 (1.80-6.19)	1.81 (0.96-2.74)	<0.001^b	3.57 (1.69-6.49)	1.90 (1.02-2.98)	<0.001^b
In-hospital mortality	16 (14.8)	23 (2.7)	<0.001	9 (18.0)	2 (2.0)	0.002^a

Variables	OR (95% CI)	P-value
Matched	3.176 (1.567-6.438)	0.001
Unmatched	2.659 (1.772-3.990)	<0.001
Subgroup analysis
Matched¹	3.103 (1.322-7.287)	0.009
Non-matched¹	2.130 (1.328-3.418)	0.002
Matched²	3.733 (0.847-16.452)	0.082
Non-matched²	5.597 (2.153-14.547)	<0.001
Matched³	7.250 (1.476-35.611)	0.015
Non-matched³	3.987 (1.861-8.542)	<0.001
Matched⁴	2.621 (1.135-6.054)	0.024
Non-matched⁴	2.909 (1.752-4.829)	<0.001

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