Abstract 1: PrePARE - fluid bolus + CV collapse in intubation

Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial Janz DR, Casey JD, Semler MW, et al. Lancet Respir Med. 2019;2600(19):1-9.

SUMMARY:

• The preventing cardiovascular collapse with administration of fluid resuscitation before tracheal intubation (PrePARE) trial was a pragmatic, multicenter, unblinded, randomized trial comparing administration of a 500-cc fluid bolus beginning before induction with no fluid bolus administration during tracheal intubation of critically ill adults.
• Eight of the sites were ICUs, and 1 site was an ED.
• The primary endpoint was a composite outcome consisting of complications including new-onset hypotension (systolic blood pressure <65 mm Hg) within 2 minutes, new or increased vasopressor administration within 2 minutes, or cardiac arrest or death within 1 hour.
• The authors planned to enroll 500 patients but stopped early after enrolling 337, because a planned interim analysis showed no difference between the groups.
• The primary composite outcome occurred in 20% of 168 patients in the fluid-bolus group versus 18% of 169 patients in the no-fluid-bolus group (absolute difference of 1.3%).
• The overall results were also similar in prespecified analyses with adjustment for age, severity of illness, receipt of vasopressors before enrollment, and lowest systolic blood pressure before enrollment, as well as per-protocol analyses.
• Many secondary outcomes were observed, including ICU days, mortality, desaturation, and hypotension, all of which were similar between groups.
• Notably, patient-level physiology may affect the value of a fluid bolus, because the patients receiving positive-pressure ventilation before intubation had better results with fluids, whereas the other patients had worse results with fluids.
• The authors do not provide the data on the ED patients as a separate group, and 500 cc of fluids might possibly have no effect on patients who have already received their initial resuscitation and are in the ICU but would affect ED patients early in their care.

PMID: 31585796

FULL ARTICLE: https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(19)30246-2/fulltext

EDITOR’S COMMENTARY: In this well-conducted RCT, the authors conclude that a 500-cc fluid bolus does not prevent cardiac collapse peri-intubation in critically ill patients. I would close the book on this practice if the authors had included more ED patients who might be under-resuscitated to start with. In my mind, the decision to provide fluids should be based on volume status; if you want to improve hemodynamics during intubation, use a pressor.

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