Induction and positive-pressure ventilation reduce venous return and sympathetic drive, so a patient in shock can arrest within minutes of intubation. The physiologically difficult airway is now treated as seriously as the anatomically difficult one.
Established practice is to correct hypotension and hypoxia as far as time allows before induction: fluids or blood where appropriate, a vasopressor running or ready, thorough preoxygenation, a reduced induction dose of a haemodynamically stable agent, and a clear plan for the first attempt.
- Have a vasopressor running or drawn up before inducing a hypotensive patient.
- Preoxygenate fully; consider non-invasive ventilation or high-flow oxygen to do it.
- Reduce the induction dose in shock and choose an agent with less haemodynamic effect.
- Brief the team on the plan for a failed first attempt before starting.
Why it matters
The minutes after induction are when the shocked patient is most likely to arrest.
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