Written by Clay Smith
Spoon Feed
A 500mL fluid bolus prior to intubation of critically ill ICU patients did not reduce the rate of cardiovascular (CV) collapse.
Why does this matter?
Intubation, with use of powerful induction agents, positive pressure, and decreased preload may result in CV collapse in up to one-quarter of patients. Would giving a fluid bolus prior to intubation help?
PrePARE yourself for a let down
This was a RCT of critically ill adult patients who were being intubated in the ICU. It was open label and randomized 337 patients to either a 500mL fluid bolus just prior to and during intubation or no fluid bolus. For the composite outcome of CV collapse (hypotension – SBP ≤65, new or increased vasopressor within 2 minutes of intubation, or arrest /death within an hour of intubation), there was no difference in the fluid bolus vs no bolus groups, 20% vs 18%, respectively – not statistically different. The study was stopped early due to futility. Most subgroups and other exploratory outcomes also did not benefit from a fluid bolus. A fluid bolus was not associated with any adverse events. Interestingly, this trial allowed co-enrollment in the PreVent trial, in which some patients received positive pressure via bag mask ventilation (BMV). There was a suggestion that patients receiving BMV may have a lower rate of CV collapse with fluid, and those not receiving BMV might actually have greater risk of CV collapse with a fluid bolus. This is an interesting observation at this point but is not conclusive.
Another Spoonful
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Get this interview on 5minuteairway with lead author Dave Janz.
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REBEL EM has an outstanding, thorough summary.
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EMCrit has great perspective on this with Josh Farkas.
Source
Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial. Lancet Respir Med. 2019 Oct 1. pii: S2213-2600(19)30246-2. doi: 10.1016/S2213-2600(19)30246-2. [Epub ahead of print]
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