Effect of a fluid bolus on cardiovascular collapse during tracheal intubation: A randomized clinical trial
Janz DR, Casey JD, Semler MW, Russell DW, Dargin J, Vonderhaar DJ, Dischert KM, West JR, Stempek S, Wozniak J, Caputo N, Heiderman BE, Zouk AN, Gulati S, Stingler WS, Bentov I, Joffe AM, Rice TW, and Jayaprakash N. Effect of a fluid bolus on cardiovascular collapse during tracheal intubation: A randomized clinical trial. Acad Emerg Med 2019; 26:S43.
Acad Emerg Med
Background: Emergency tracheal intubation of critically ill adults is frequently complicated by hypotension, cardiac arrest, or death. Whether administration of an intravenous fluid bolus reduces the risk of peri-intubation cardiovascular collapse is unknown. Methods: We conducted a multicenter, two-armed, parallel-group, unblinded randomized controlled trial at nine US sites to evaluate the effectiveness of administering a 500 ml fluid bolus during rapid sequence intubation of critically-ill adults for preventing cardiovascular collapse. By opening opaque envelopes after the decision to intubate and before induction, we randomized patients to receive either a 500 ml fluid bolus started before induction (experimental group), or no fluid bolus (control group). The primary outcome was cardiovascular collapse, defined as the composite of: new systolic blood pressure <65 mmHg; new or increased vasopressor receipt between induction and two minutes after intubation; cardiac arrest within one hour of intubation; or death within one hour of intubation. Results: The data and safety monitoring board stopped the trial for futility at the first planned interim analysis, which occurred after 337 patients had been enrolled. The primary outcome of cardiovascular collapse occurred in 33 of 168 patients (19.6%) in the fluid bolus group compared with 31 of 169 patients (18.3%) in the no fluid bolus group (absolute between-group difference, 1.3% [95% CI,-7.1% to 9.7%]). Individual components of the cardiovascular collapse composite outcome were not significantly different between groups. Bag-mask ventilation between induction and laryngoscopy modified the effect of fluid bolus administration on the rate of cardiovascular collapse (P value for interaction = .01). Fluid bolus administration appeared to decrease the rate of cardiovascular collapse among patients receiving bag-mask ventilation and increase the rate of cardiovascular collapse among patients not receiving bag-mask ventilation Conclusion: Administration of an intravenous fluid bolus during emergency tracheal intubation of critically ill adults did not decrease the overall rate of cardiovascular collapse compared to no fluid bolus. The effect of fluid bolus administration on cardiovascular collapse may depend on the receipt of bag-mask ventilation during intubation. (clintrials.gov: NCT03026777)