Reviews to Elevate Your Airway Practice
A review article on the 2022 PREPARE II trial published in JAMA:
We first featured this study in our Physiologically Difficult Airway curriculum in 2022; however, the ritual persists in many clinical settings. The pre-intubation fluid bolus remains a common practice, administered in the hope of preventing hypotension and averting cardiovascular collapse. But is this habit grounded in evidence or just tradition? The answer was unknown until 2022, when Derek W. Russell and colleagues published the PREPARE II trial to answer that very question: Does giving a fluid bolus before intubation actually reduce the risk of cardiovascular collapse?
Summary of the Study:
This multicenter, randomized clinical trial enrolled 1,067 critically ill adults undergoing tracheal intubation across 11 U.S. intensive care units (ICUs). During the peri-intubation period, patients were randomized to receive either a 500 mL crystalloid fluid bolus or no bolus.
The primary outcome was cardiovascular collapse, defined as vasopressor initiation or escalation, systolic blood pressure <65 mm Hg, cardiac arrest, or death within one hour post-induction. The results?
- Cardiovascular collapse occurred in 21.0% of patients in the fluid bolus group vs. 18.2% in the no bolus group — a difference that was not statistically significant.
- Secondary outcomes—including 28-day mortality, ventilator-free days, and ICU-free days—also showed no significant benefit from the fluid bolus.
Bottom Line:
In patients undergoing intubation with positive pressure ventilation, a routine 500 mL fluid bolus did not reduce the risk of cardiovascular collapse, cardiac arrest, or short-term mortality.
Take-Home Message:
The fluid bolus before intubation may be a ritual worth retiring. This large, pragmatic trial shows that skipping the bolus is just as safe, and may streamline decision-making in critical moments. This doesn’t mean fluids have no role in the resuscitation of critically ill patients; it means we shouldn’t reflexively spike the bag. Instead, we should focus on targeted strategies, including the use of early vasopressors, thoughtful selection of induction agents, and careful pre-intubation planning.
Clinical Implications:
Every unnecessary step during a critical procedure diverts time, focus, and personnel. When every second matters, there’s no room for autopilot. Rethink the reflexive bolus. Do it for a reason, not out of habit.
Yes, There’s a Better Way to Train for the Physiologically Difficult Airway
Print Them, Set Them Up, Grab Some Equipment, Start Training
The topic of fluids is just one aspect of managing critical physiology in the peri-intubation period. Our unique educational design bridges the gap between online content and hands-on practice. Print the posters below, set them up in any available space, gather your equipment, and let your team get started. It’s flexible, scalable, and ready to go — perfect for residency training, faculty development, or team-based airway drills, whether you’re running sessions inside the hospital or building skills out in the field. 👉 Visit the Learning Space.
Fluids: Deep Cuts
For more information on the role of fluids in the peri-intubation period and how to manage it effectively, visit this topic in our course curriculum. Then, dive into our whole learning space on the physiologically difficult airway.
