A Life Saving Bolus? IV Fluids at the Time of Intubation

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Russell, D. W. et al. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation. Jama 328, 270–279 (2022).

  • P: adult ICU patients undergoing endotracheal intubation with preoxygenation via positive pressure ventilation (BVM or NIPPV)

  • I: 500 cc crystalloid bolus prior to induction

  • C: No fluid bolus

  • O: No difference in primary outcome of incidence of cardiovascular collapse (defined as one or more of the following: new or increased vasopressor requirement between induction of anesthesia and 2 minutes after tracheal intubation, a new systolic BP <65 mmHg between induction and 2 minutes after tracheal intubation, or cardiac arrest of death between induction of anesthesia and 1 hour after intubation), no difference in secondary outcome of death at 28 days

Background

Estimates state that 40-50% of patients undergoing endotracheal intubation receive a fluid bolus peri-induction. The risk of the development of hypotension and associated risk of cardiac arrest and death urges providers to attempt to resuscitate before intubation, which may include this practice of providing a fluid bolus. The PrePARE trial was published in 2019 and examined the rate of cardiovascular collapse in patients who did and did not receive a fluid bolus peri-induction. This study concluded no significant difference in rate of cardiovascular collapse between groups. However, in subgroup analysis, there was signal to suggest fluid bolus may be helpful in patients undergoing positive pressure ventilation between induction of anesthesia and laryngoscopy, and thus the PrePARE II trial was born to examine this.

Methods

This was an unblinded, multicenter randomized clinical trial conducted across ICUs in 11 centers. Adult patients undergoing endotracheal intubation with plans for positive pressure ventilation use between induction of anesthesia and laryngoscopy (via BVM or NIPPV) were randomized to receive a 500 cc fluid bolus prior to induction or no bolus. Exclusions included pregnant patients,  incarcerated patients, patients in whom intubation was felt to be too emergent and thus not able to be randomized given time constraints, and those for whom the operator/proceduralist felt a fluid bolus was either definitely indicated or definitely contraindicated. Management of intubation, including sedative, paralytic, preoxygenation, and intubation technique was left to the discretion of the operator.

The primary outcome of interest was cardiovascular collapse, which the authors defined as the occurrence of one or more of the following: new or increased vasopressor requirement between induction of anesthesia and 2 minutes after tracheal intubation, a new systolic BP <65 mmHg between induction and 2 minutes after tracheal intubation, or cardiac arrest of death between induction of anesthesia and 1 hour after intubation. The secondary outcome of interest was incidence of death by day 28.

Results and Conclusion

A total of 1065 patients were ultimately included in the trial. Demographics were similar between the fluid bolus and no bolus groups. A fluid bolus was received as intended in 99.4% of the fluid bolus group. Cardiovascular collapse occurred in 21% of the fluid bolus and 18.2% of the no fluid bolus group. This difference was not statistically significant. There was no statistically significant difference seen in the secondary outcome of death by 28 days. Authors concluded that a fluid bolus did not significantly decrease the incidence of cardiovascular collapse in patients undergoing endotracheal intubation with positive pressure ventilation between induction and laryngoscopy.

Limitations

This trial has a few important limitations to note. First, patients were excluded if intubation was too emergent for the patient to undergo randomization and trial procedures, and thus the results may not be generalizable to patients in cardiac/respiratory arrest or who otherwise require very emergent intubation. Secondly, the study examined only a fluid bolus of 500 cc but the study notably did not account for patients’ fluid balance prior to intubation. Further, we were provided with the data for the breakdown of agents used for both sedative and paralytic but the doses used were not provided and this may be significant in terms of effect on patient hemodynamics. Additionally, the study was not blinded, which may introduce bias. Authors also mentioned limitations regarding whether new or increased vasopressor requirement is a patient-centered end point. Also discussed was that this study does not provide guidance regarding whether a bolus for treatment of the development of peri-intubation hypotension may be useful, rather than for prevention.

Authorship

Written by: Courtney Kein, MD, PGY-3 University of Cincinnati Department of Emergency Medicine

Peer Review, Editing, and Posting by: Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine

CIte As

Kein, C. Hill, J. (August 31, 2022) A Life Saving Bolus? IV Fluids at the Time of Intubation. TamingtheSRU. https://www.tamingthesru.com/blog/journal-club/a-life-saving-bolus-iv-fluids-at-the-time-of-intubation.