Original Investigation 

June 16, 2022

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

Derek W. Russell, Jonathan D. Casey, Kevin W. Gibbs, et al

JAMA. Published online June 16, 2022. doi:10.1001/jama.2022.9792

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