• Derek W Russell, Jonathan D Casey, Kevin W Gibbs, Shekhar Ghamande, James M Dargin, Derek J Vonderhaar, Aaron M Joffe, Akram Khan, Matthew E Prekker, Joseph M Brewer, Simanta Dutta, Janna S Landsperger, Heath D White, Sarah W Robison, Joanne M Wozniak, Susan Stempek, Christopher R Barnes, Olivia F Krol, Alejandro C Arroliga, Tasnim Lat, Sheetal Gandotra, Swati Gulati, Itay Bentov, Andrew M Walters, Kevin M Dischert, Stephanie Nonas, Brian E Driver, Li Wang, Christopher J Lindsell, Wesley H Self, Todd W Rice, David R Janz, Matthew W Semler, and PREPARE II Investigators and the Pragmatic Critical Care Research Group.
• Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham.
• JAMA. 2022 Jul 19; 328 (3): 270279270-279.

ImportanceHypotension 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.ObjectiveTo determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death.Design, Setting, And ParticipantsThis 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.InterventionsPatients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527).Main Outcomes And MeasuresThe 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.ResultsAmong 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 RelevanceAmong 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 RegistrationClinicalTrials.gov Identifier: NCT03787732.

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