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Original Investigation
June 16, 2022

Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial

Author Affiliations
  • 1Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
  • 2Pulmonary Section, Birmingham Veteran’s Affairs Medical Center, Birmingham, Alabama
  • 3Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 4Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
  • 5Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
  • 6Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
  • 7Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
  • 8Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
  • 9Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
  • 10Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
  • 11Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
  • 12Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Mississippi Medical Center, Jackson
  • 13Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 14Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
  • 15University Medical Center New Orleans, New Orleans, Louisiana
  • 16Section of Pulmonary/Critical Care and Allergy/Immunology, Department of Medicine, Louisiana State University School of Medicine, New Orleans
JAMA. 2022;328(3):270-279. doi:10.1001/jama.2022.9792
Visual Abstract. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Patients Undergoing Tracheal Intubation
Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Patients Undergoing Tracheal Intubation
Key Points

Question  In critically ill adult patients undergoing tracheal intubation, does intravenous infusion of a crystalloid solution as a 500-mL fluid bolus decrease the incidence of severely low blood pressure, cardiac arrest, or death (referred to as cardiovascular collapse) during or shortly after the procedure?

Findings  In this randomized clinical trial that included 1065 critically ill adults, the incidence of cardiovascular collapse was 21.0% with administration of a fluid bolus vs 18.2% without administration of a fluid bolus, a difference that was not statistically significant.

Meaning  Among critically ill adults undergoing tracheal intubation, administration of a fluid bolus did not significantly decrease the incidence of cardiovascular collapse.

Abstract

Importance  Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain.

Objective  To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death.

Design, Setting, and Participants  This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021.

Interventions  Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527).

Main Outcomes and Measures  The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge.

Results  Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, −2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, −1.8% [95% CI, −7.9% to 4.3%]; P = .55).

Conclusions and Relevance  Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse.

Trial Registration  ClinicalTrials.gov Identifier: NCT03787732

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    1 Comment for this article
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    Use Volume Responsiveness to Guide Rapid IV Infusion Prior to Intubation
    Lawrence Loh, MD | Zhongshan hospital, Fudan University
    This is a well-designed study intended to answer a straightforward clinical question. The physiological effect of rapid fluid infusion on the risk of cardiovascular collapse may be greatest in patients receiving positive pressure ventilation during induction of anesthesia, as positive pressure ventilation reduces the amount of venous blood returning to the heart. This study did not find that fluid infusion reduced the incidence of cardiovascular collapse among critically ill patients undergoing tracheal intubation. I noticed that this study did not report volume status before intubation, and it is recognized that rapid intravenous fluid infusion prior to intubation can be harmful if the patient is volume-overloaded. 15 % of the patient population was diagnosed with congestive heart failure, and rapid fluid infusion may be damaging for these patients. If it is expected that the majority of sepsis patients are sufficiently resuscitated, then a considerable number of these patients will also be over-infused. Infusing 500 ml of fluid rapidly in the several minutes before intubation may do more harm than good for many patients. This study did not perform a subgroup analysis based on cardiac functional status or volume variables. In the future, we may be able to assess the necessity for pre-intubation fluid infusion by estimating volume response soon after intubation, which could make it easier for patients to gain benefit.
    CONFLICT OF INTEREST: None Reported
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