Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation

Russell, Derek W.; Casey, Jonathan D; Gibbs, Kevin W.; Ghamande, Shekhar; Dargin, James; Vonderhaar, Derek J; Joffe, Aaron M.; Khan, Akram; Prekker, Matthew E.; Brewer, Justin; Dutta, Simanta; Landsperger, Janna S.; White, Heath; Robison, Sarah; Wozniak, Joanne; Stempek, Susan; Barnes, Christopher; Krol, Olivia; Arroliga, Alejandro C.; Lat, Tasnim; Gandotra, Sheetal; Gulati, Swati; Bentov, Itay; Walters, Andrew M.; Dischert, Kevin M; Nonas, Stephanie; Driver, Brian E.; Wang, Li; Lindsell, Christopher J.; Self, Wesley H.; Rice, Todd W.; Janz, David R.; Semler, Matthew W.

doi:10.1001/jama.2022.9792

Cited by 49 publications

(32 citation statements)

References 29 publications

(62 reference statements)

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“…This global strategy including pre-intubation fluid infusion provided convincing results. However, two recent randomized controlled trials challenged the benefit of systematic fluid infusion before intubation to prevent PIHI in a non-selected population of critically ill patients [ 31 , 32 ]. A combination of tissue perfusion parameters and MAP, which increased the prediction of PIHI, may be of interest for tailored intervention and to limit fluid overload, associated with poor outcome in ICU [ 33 ].…”

Section: Discussionmentioning

confidence: 99%

Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability

Dubée

Hariri

Joffre

et al. 2022

Ann. Intensive Care

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Background Tracheal intubation and invasive mechanical ventilation initiation is a procedure at high risk for arterial hypotension in intensive care unit. However, little is known about the relationship between pre-existing peripheral microvascular alteration and post-intubation hemodynamic instability (PIHI). Methods Prospective observational monocenter study conducted in an 18-bed medical ICU. Consecutive patients requiring tracheal intubation were eligible for the study. Global hemodynamic parameters (blood pressure, heart rate, cardiac function) and tissue perfusion parameters (arterial lactate, mottling score, capillary refill time [CRT], toe-to-room gradient temperature) were recorded before, 5 min and 2 h after tracheal intubation (TI). Post intubation hemodynamic instability (PIHI) was defined as any hemodynamic event requiring therapeutic intervention. Results During 1 year, 120 patients were included, mainly male (59%) with a median age of 68 [57–77]. The median SOFA score and SAPS II were 6 [4–9] and 47 [37–63], respectively. The main indications for tracheal intubation were hypoxemia (51%), hypercapnia (13%), and coma (29%). In addition, 48% of patients had sepsis and 16% septic shock. Fifty-one (42%) patients develop PIHI. Univariate analysis identified several baseline factors associated with PIHI, including norepinephrine prior to TI, sepsis, tachycardia, fever, higher SOFA and high SAPSII score, mottling score ≥ 3, high lactate level and prolonged knee CRT. By contrast, mean arterial pressure, baseline cardiac index, and ejection fraction were not different between PIHI and No-PIHI groups. After adjustment on potential confounders, the mottling score was associated with a higher risk for PIHI (adjusted OR: 1.84 [1.21–2.82] per 1 point increased; p = 0.005). Among both global haemodynamics and tissue perfusion parameters, baseline mottling score was the best predictor of PIHI (AUC: 0.72 (CI 95% [0.62–0.81]). Conclusions In non-selected critically ill patients requiring invasive mechanical ventilation, tissue hypoperfusion parameters, especially the mottling score, could be helpful to predict PIHI.

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Section: Discussionmentioning

confidence: 99%

Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability

Dubée

Hariri

Joffre

et al. 2022

Ann. Intensive Care

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“…It is worth noting that the amount of fluid given was very low, which can partially explain the results, and that it was not combined with systematic vasoactive support. Recently, a randomized controlled trial enrolling 1067 critically ill patients undergoing tracheal intubation [ 81 ] reported that administration of an intravenous fluid bolus alone without associated to a systematic administration of norepinephrine compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse. The FLUVA trial (NCT05318066) is currently underway to assess the effect of fluid loading and introduction of vasopressors before the tracheal intubation to reduce severe cardiovascular collapse.…”

Section: Hemodynamic Optimization and Choice Of Drugsmentioning

confidence: 99%

How to improve intubation in the intensive care unit. Update on knowledge and devices

et al. 2022

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Tracheal intubation in the critically ill is associated with serious complications, mainly cardiovascular collapse and severe hypoxemia. In this narrative review, we present an update of interventions aiming to decrease these complications. MACOCHA is a simple score that helps to identify patients at risk of difficult intubation in the intensive care unit (ICU). Preoxygenation combining the use of inspiratory support and positive end-expiratory pressure should remain the standard method for preoxygenation of hypoxemic patients. Apneic oxygenation using high-flow nasal oxygen may be supplemented, to prevent further hypoxemia during tracheal intubation. Face mask ventilation after rapid sequence induction may also be used to prevent hypoxemia, in selected patients without high-risk of aspiration. Hemodynamic optimization and management are essential before, during and after the intubation procedure. All these elements can be integrated in a bundle. An airway management algorithm should be adopted in each ICU and adapted to the needs, situation and expertise of each operator. Videolaryngoscopes should be used by experienced operators.

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“…This is consistent with previous randomized trials comparing alternative approaches to tracheal intubation commonly used in clinical care. 28,38,39,[45][46][47][48][49][50] This approach was approved by the US Department of Defense (DoD) Defense Health Agency Human Research Protection Office (EIRB# 944893).…”

Section: Waiver Of Informed Consentmentioning

confidence: 99%

DirEct Versus VIdeo LaryngosCopE (DEVICE): Protocol and statistical analysis plan for a randomized clinical trial in critically ill adults undergoing emergency tracheal intubation

Prekker

Trent

Resnick-Ault

et al. 2022

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Introduction: Among critically ill patients undergoing orotracheal intubation in the emergency department (ED) or intensive care unit (ICU), failure to visualize the vocal cords and intubate the trachea on the first attempt is associated with an increased risk of complications. Two types of laryngoscopes are commonly available: direct laryngoscopes and video laryngoscopes. For critically ill adults undergoing emergency tracheal intubation, it remains uncertain whether use of a video laryngoscope increases the incidence of successful intubation on the first attempt compared with use of a direct laryngoscope. Methods and Analysis: The DirEct Versus VIdeo LaryngosCopE (DEVICE) trial is a prospective, multi-center, non-blinded, randomized trial being conducted in 6 EDs and 10 ICUs in the United States. The trial plans to enroll up to 2,000 critically ill adults undergoing orotracheal intubation with a laryngoscope. Eligible patients are randomized 1:1 to the use of a video laryngoscope or a direct laryngoscope for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is the incidence of severe complications between induction and 2 minutes after intubation, defined as the occurrence of one or more of the following: severe hypoxemia (lowest oxygen saturation < 80%); severe hypotension (systolic blood pressure < 65 mm Hg or new or increased vasopressor administration); cardiac arrest; or death. Enrollment began on March 16, 2022 and is expected to be completed in 2023. Ethics and Dissemination: The trial protocol was approved with waiver of informed consent by the single institutional review board at Vanderbilt University Medical Center and the Human Research Protection Office of the Department of Defense. The results will be presented at scientific conferences and submitted for publication in a peer-reviewed journal. Trial Registration ClinicalTrials.gov registration (NCT05239195) on February 14, 2022, prior to the enrollment of the first patient.

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Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation

Cited by 49 publications

References 29 publications

Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability

Peripheral tissue hypoperfusion predicts post intubation hemodynamic instability

How to improve intubation in the intensive care unit. Update on knowledge and devices

DirEct Versus VIdeo LaryngosCopE (DEVICE): Protocol and statistical analysis plan for a randomized clinical trial in critically ill adults undergoing emergency tracheal intubation

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