Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically ill Patients

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, according to recent research published in JAMA.

Hypotension during tracheal intubation results, in part, from medication-induced vasodilation and decreased return of venous blood to the heart due to increased intrathoracic pressure from positive pressure ventilation. The intravenous administration of a crystalloid solution (referred to as a fluid bolus) might counteract these effects by transiently increasing intravascular volume. Current international guidelines and expert recommendations suggest that critically ill adults undergoing tracheal intubation receive a fluid bolus.

A fluid bolus is administered during approximately 40% to 50% of emergency tracheal intubations in current clinical practice. 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. Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus or no fluid bolus.

Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis. The cardiovascular collapse occurred in 113 patients in the fluid bolus group and in 96 patients in the no fluid bolus group. 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, and 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 occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group.

Thus the authors concluded that 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.