NextGen Learning To Elevate Your Airway Practice
Review fluids before intubation and the supporting evidence within the physiologically difficult airway PACscape. Continue with vasopressors for peri-intubation hypotension.
Start Here
Overview
Let’s discuss another critical aspect of airway management that often sparks debate: fluid administration during the peri-intubation period. When you’re gearing up to intubate a critically ill patient, the question arises—to give fluids or not to give? Traditionally, administering a fluid bolus before intubation was almost a reflex. The idea was to stave off potential hypotension during the procedure, but recent evidence suggests a more nuanced approach.
Assess Need
Whether to or not to give fluids is more nuanced than it may appear—the three questions you need to ask to make that assessment are:
- Are they hypotensive now (before intubation)?
- What is their current volume status?
- What is their current cardiac function?
- You can start with 500cc of fluid, but you should also rapidly assess volume status and look for other causes of hypotension before deciding if more fluids are indicated.
News Update: normal saline is just fine (didn’t we already know that?) Don’t let anyone tell you otherwise.
What to Give
Yes, it’s okay to give normal saline
Balanced fluids or normal saline. We can finally end this debate. The BaSICS trial can put your mind at rest on this one. This BOTTOM LINE of a great review from Justing Morgenstern sums it up.
“This is the best and largest study of normal saline and balanced IV fluids to date, and it is pretty clear that normal saline is as safe as the balanced fluid. (Whether providing either IV fluid to these patients is beneficial is a completely different question.) Continue to use whatever is easiest for your team. I still almost always use saline myself.”
Morgenstern, J. The BaSICS trial: Normal saline has been fine all along, First10EM, August 11, 2021. Available at:https://doi.org/10.51684/FIRS.83995
🔑 Key Takeaway
The debate between balanced fluids and normal saline has been ongoing. However, the BaSICS trial reassures that normal saline is as safe as balanced fluids. So, use what’s readily available and familiar to your team.
Fluids to Prevent Intubation Hypotension?
What is the evidence for this practice? Recent studies have called the value of fluids in the peri-intubation period into question. We summarize it below and give you access to the deeper dive on RebelEM.
Clinical Take Home Point: “Putting all the evidence together (PrePARE and PrePARE II), the administration of 500mLs of fluid before intubation does not seem to decrease the incidence of cardiovascular collapse in critically ill adult patients undergoing tracheal intubation and should not be routine practice. “Resuscitate before you intubate” is a nuanced procedure that requires focused interventions based on the patient’s pathophysiology”. – RebelEM. Another great way to build your learning network 💪
- Russell DW et al. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA 2022. PMID: 35707974 [Access on Read by QxMD]
- Janz DR et al. PrePARE Investigators; Pragmatic Critical Care Research Group. Effect of Fluid Bolus on Cardiovascular Collapse Among Critically Ill Adults Undergoing Tracheal Intubation (PrePARE): A Randomised Controlled Trial. Lancet Respir Med 2019 PMID: 31585796
🔑 Key Takeaway
Studies like PrePARE and PrePARE II suggest that this practice does not significantly decrease the incidence of cardiovascular collapse during intubation in critically ill adults. Fluid administration should be tailored to the patient’s pathophysiology rather than applied universally.
Expert Tips
Spike a Bag
Do you know how to spike a bag of fluids? It seems simple enough, but you should know how to do it correctly. Watch this video and then head to the practice station associated with this poster.
EXPERT Pearl
This is a short public service announcement. Regardless of your access, don’t put those fluids on a pump. If you need volume in your patient fast, use a pressure bag instead. For more on why this is true, check out this Twitter thread by Dr. Sam Ghali, and then don’t forget to add him to your learning network.
🔎Expert Tip:
If rapid fluid administration is necessary, avoid using infusion pumps, which can be slow. Instead, employ a pressure bag to expedite delivery. This approach ensures that the patient receives the required volume promptly, which can be crucial in emergent situations.
Bottom Line
Fluid management during the peri-intubation period isn’t a one-size-fits-all scenario’s essential to assess each patient’s unique needs, understand the latest evidence, and apply clinical judgment to optimize outcomes
What’s Next
Find Or Click Me
Nice work—you’re through this section! To keep going, scan the QR code on the physical poster at the next station in our pop-up training space to access the next set of digital content. Prefer to stay online? Just click the poster image here to continue your journey.
You must be logged in to post a comment.