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Three Part Question

In [ pre-intubation normotensive adult patients], does [the administration of IV crystalloid bolus] decrease the risk of [peri-intubation hypotension, cardiac arrest, ICU admission, or death]?

Clinical Scenario

A 53-year-old patient presents to the Emergency Department with an altered level of consciousness from a suspected respiratory failure. The decision was made to intubate him. As you are preparing to intubate the patient, you wonder whether pre-intubation IVF bolus administration in your normotensive patient will reduce the risk of peri-intubation complications.

Search Strategy

OVID Medline Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to Present


(infusions, intravenous/mt [Methods] OR crystalloid solutions/ad, tu [Administration & Dosage, Therapeutic use] OR fluid therapy/mt [Methods] OR colloids/ad, tu [Administration & Dosage, Therapeutic use])

AND

(male OR female OR middle aged OR aged OR emergency service, hospital OR critical illness OR intensive care units OR critical care OR perioperative care/mt [methods])

AND

(hypotension/pc [prevention & control] OR anesthesia, endotracheal OR intubation, intratracheal/ OR "rapid sequence induction and intubation" OR ventilators, mechanical OR respiration, artificial OR shock/pc [prevention & control])

AND

(treatment outcome OR incidence OR blood pressure/de OR hypotension/de, ep [drug effects, epidemiology] OR death/de, pc [drug effects, prevention & control] OR mortality/de [drug effects] OR hemodynamics/de [drug effects] OR treatment outcome/ OR shock/ep [epidemiology])

78 papers were found of which 2 were relevant and included in this review.

Search Outcome

The current data doesn’t support giving pre-intubation IVF bolus in normotensive patients and there is insufficient evidence support administering pre-intubation IVF bolus in patients with positive pressure ventilation to decreases the incidence of cardiovascular collapse.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tomi Myrberg 2019 Sweden	80 patients scheduled for non-cardiac surgery from a single center	RCT	MAP drop below 65 mmHg during the first 20 minutes after anesthesia induction in RSI & TCI groups	23 of 40 patients without preoperative IVF bolus had BPD below MAP 65 mmHg 5 of 40 patients with preoperative IVF bolus had BPD below MAP 65 mmHg P-value <0.001	The volume of intravenous fluids that patients received before enrolment was not recorded and IVF bolus was started in preoperative ward unit. controlled population compared to patient in emergency department / critical care A routine use of atropine in all patients may have increased hemodynamic stability in both groups Limited power The study was conducted in a single center study which may restrict the generalizability induction
			MAP drop below 65 mmHg during the first 20 minutes after anesthesia induction in RSI group only	12 of 20 patients without preoperative fluids had BPD below MAP 65 mm Hg 3 of 20 patients with preoperative IVF had BPD below MAP 65 mm Hg P value < .001
			MAP drop below 65 mmHg during the first 20 minutes after anesthesia induction in TCI group only	11 of 20 patients without preoperative IVF had BPD below MAP 65 mm Hg 2 of 20 patients with preoperative IVF had BPD below MAP 65 mm Hg P value < .001

Comment(s)

A search in the literature for prei-intubation IVF bolus usage shows few papers from anesthetic & ICU practice demonstrating patients with PPV, either by NIV before induction or BMV after induction, had decreased incidence of cardiovascular collapse after administration of pre-intubation IVF bolus compared with no fluid bolus. For patients without PPV, pre-intubation IVF bolus might increase the risk of cardiovascular collapse compared with no fluid bolus. The explanation of this phenomenon is thought to be secondary to dilution of endogenous catecholamines, stimulation of atrial natriuretic peptide release, and damage to the glycocalyx. Overall, there is no significant difference in ICU admission, cardiac arrest, or mortality in patients with pre-intubation IVF compared to no IVF. These findings could be affected by the timing and volume of pre-intubation IVF. A half-litre of crystalloid is commonly used as IVF bolus volume in the reviewed papers, and this might have been inadequate to influence patient hemodynamics during intubation. Furthermore, the timing of IVF bolus administration was not mandated to start immediately before induction & intubation. Finally, starting IVF before induction & infusing it throughout the peri-intubation period might have produced different results than if the entire bolus had been administered before induction.

Clinical Bottom Line

The current data doesn’t support giving pre-intubation IVF bolus in normotensive patients and there is insufficient evidence support administering pre-intubation IVF bolus in patients with positive pressure ventilation to decreases the incidence of cardiovascular collapse.

References

1. David R Janz Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial Lancet Respir Med 2019; 7: 1039–47 Published Online October 1, 2019 Lancet Respir Med 2019; 7: 1039–47 Published Online October 1, 2019
2. Tomi Myrberg Effect of preoperative fluid therapy on hemodynamic stability during anesthesia induction, a randomized study Published by John Wiley & Sons Ltd Acta Anaesthesiol Scand. 2019;63:1129–1136.