October 2022

Clinical Question

Resuscitation before intubation…Does an IV fluid bolus before intubation of critically unwell adult prevent severe hypotension?

Title of Paper

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

Journal and Year

JAMA. 2022.

Lead Author

Derek Russell

Background

– It’s pretty routine to give an IV fluid bolus before and during RSI (and is included in most airway checklists)
– The PrePARE study in 2019 (a multicentre trial in 9 US ICUs) showed no benefit in fluid bolus administration before/during emergency intubation of ICU patients. They did have a subgroup of patients that received positive pressure ventilation during the apnoic period that looked like they benefitting from the fluid bolus, however. The theory being that it helps with the preload impairment you get from PPV.

Study Design

– Multicentre, parallel-group, unblinded, pragmatic randomised clinical trial
– 11 US ICUs

Patients Studied

– Adults undergoing RSI and positive pressure ventilation during apnoic period

Intervention

– 500ml of IV/IO crystalloid – aiming to infuse as much as possible before induction without delaying the procedure with the residual being given during intubation.

Comparison

– IV fluid administration not permitted, except:
– as treatment for hypotension
– operator determined necessary for patient safety

Outcomes

– Primary: cardiovascular collapse – ≥1 of:
– New or increased receipt of vasopressors (from induction → 2 minutes post intubation)
– SBP <60mmHg (from induction → 2 minutes post intubation)
– Cardiac arrest (from induction → 1 hour post intubation)
– Death (from induction → 1 hour post intubation)
– Secondary: death by 28 days

Summary of Results

– 1065 included (met sample size target)
– Median 62 years
– 60% respiratory failure
– 20% receiving vasopressors
– 10% receiving fluids

– Primary: No difference in rate of CV collapse – 21% of fluid group vs 18% of no fluid group
– Absolute diff 2.8% [-2.2 – 7.7%, p=0.25]
– Secondary: Death by 28 days – 40.5 vs 42.5%
– Absolute difference -1.8% [-7.9 – 4.3%, p-0.55]

Authors Conclusion

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.

Clinical Bottom Line

I think this study gives pretty definitive evidence that “ICU patients” don’t benefit from an additional bolus of IV fluid for urgent RSI. However, our patients are not ICU patients and there is no data on how much fluid these patients had prior to their intubation. ED patients are usually early in the resuscitation process and may still be under-filled and so may well benefit from a fluid bolus.

That being said, we also shouldn’t be relying on our fluid bolus to prevent CV collapse in our ED RSI patients. My practice is that if a patient’s BP looks a bit average, or I think there’s good potential for it to dump on induction, then I will start peripheral pressors (usually norad) before the drugs are given. I’ll even aim for the MAP to be a little higher (75 or so) to give me that wiggle room, it can always be dropped or stopped after the intubation is successful.

Acute care toolkit 16: Acute medical care for people with a learning disability

Cardiac Arrest Symposium

Process

00:31 James Raitt – Defibrillation Strategies
04:12 Darren Best and Mark Hodkinson – Improving cardiac arrest management at a local level
07:33 Rory Saggers – Experiences from London Advanced Paramedic Practitioners

Beyond ALS

11:51 Paul Rees – Haemodynamic guided CPR and REBOA
15:49 Iain Carroll – ECMO CPR
22:24 Rupert Simpsons – Cardiac Arrest Centres

Creative Careers in Emergency Medicine Part 1 – Career Longevity – Lois Brand

Management of STEMI and its Complications – Jason Kendall

EM Quizzes – RCEMLearning Team