Pre-emptive Circulatory Support Before Emergency Tracheal Intubation: A Systematic Review
7 affiliations
- 1Emergency, Medicine and Critical Care, King Fahad Central Hospital, Jazan, SAU
- 2Faculty of Medicine, Jazan University, Jazan, SAU
- 3College of Medicine, King Khalid University, Abha, SAU
- 4College of Medicine, Al-Rayan Colleges, Al-Madinah Al-Munawwarah, SAU
- 5Faculty of Medicine, Tabuk University, Tabuk, SAU
- 6College of Medicine, Taif University, Taif, SAU
- 7College of Medicine, King Faisal University, Al-Ahsa, SAU
Abstract
Emergency tracheal intubation is associated with peri-intubation cardiovascular collapse, and pre-emptive circulatory support is frequently used to mitigate this risk despite uncertain evidence. We conducted a systematic review of randomised and comparative non-randomised studies evaluating pre-emptive circulatory support initiated before or at induction in adults undergoing emergency or urgent tracheal intubation. Eligible interventions included prophylactic vasopressors, intravenous fluid boluses, hypertonic saline, blood products, deliberate circulation-first strategies, and multi-component care bundles. The primary outcome was peri-intubation cardiovascular collapse within 30 minutes of induction, defined according to individual study criteria. MEDLINE via PubMed, the Cochrane Central Register of Controlled Trials, Scopus, and Web of Science Core Collection were searched from inception to 30 August 2026, with additional searches of ClinicalTrials.gov and citation lists. Risk of bias (RoB) was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomised trials and the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for non-randomised studies. Fourteen independent cohorts comprising two randomised trials and 12 comparative non-randomised studies, with more than 7,400 participants overall, were included. Two randomised trials evaluated a pre-emptive 500 mL crystalloid bolus and found no reduction in peri-intubation cardiovascular collapse. Observational evidence for prophylactic vasopressors was inconsistent, with substantial changes between crude and adjusted estimates and substantial concerns regarding confounding. Studies evaluating circulation-first strategies or pre-intubation blood products generally reported associations favouring earlier circulatory resuscitation, but these findings were strongly influenced by confounding and treatment selection. Multi-component care bundles were also associated with fewer peri-intubation complications, but the independent contribution of their circulatory components could not be determined. Overall, the available evidence indicates that pre-emptive crystalloid administration does not reduce peri-intubation cardiovascular collapse, while evidence for prophylactic vasopressors, circulation-first strategies, and multi-component interventions remains insufficient to support routine use. Further randomised trials are needed, particularly among physiologically high-risk adults.
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BibTeX
@article{ayyashi2026preemptive,
title = {{Pre-emptive Circulatory Support Before Emergency Tracheal Intubation: A Systematic Review}},
author = {Ali J Ayyashi and Majd T Alhazmi and Mohammed S Majrabi and Abdulaziz A Aqdi and Mohammed A Zaeri and Abdullah A Alshamrani and Rahiq M Hakami and Maram A Alsamti and Mashael M Alharthy and Saleh A Alquraini and Hassan Habib AlKhalaf},
journal = {Cureus},
year = {2026},
month = sep,
doi = {10.7759/cureus.117159},
url = {https://europepmc.org/article/PMC/PMC13718881},
note = {CC BY},
}
RIS
TY - JOUR
TI - Pre-emptive Circulatory Support Before Emergency Tracheal Intubation: A Systematic Review
AU - Ali J Ayyashi
AU - Majd T Alhazmi
AU - Mohammed S Majrabi
AU - Abdulaziz A Aqdi
AU - Mohammed A Zaeri
AU - Abdullah A Alshamrani
AU - Rahiq M Hakami
AU - Maram A Alsamti
AU - Mashael M Alharthy
AU - Saleh A Alquraini
AU - Hassan Habib AlKhalaf
PY - 2026
DA - 2026/09/29
JO - Cureus
DO - 10.7759/cureus.117159
UR - https://europepmc.org/article/PMC/PMC13718881
AB - Emergency tracheal intubation is associated with peri-intubation cardiovascular collapse, and pre-emptive circulatory support is frequently used to mitigate this risk despite uncertain evidence. We conducted a systematic review of randomised and comparative non-randomised studies evaluating pre-emptive circulatory support initiated before or at induction in adults undergoing emergency or urgent tracheal intubation. Eligible interventions included prophylactic vasopressors, intravenous fluid boluses, hypertonic saline, blood products, deliberate circulation-first strategies, and multi-component care bundles. The primary outcome was peri-intubation cardiovascular collapse within 30 minutes of induction, defined according to individual study criteria. MEDLINE via PubMed, the Cochrane Central Register of Controlled Trials, Scopus, and Web of Science Core Collection were searched from inception to 30 August 2026, with additional searches of ClinicalTrials.gov and citation lists. Risk of bias (RoB) was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for randomised trials and the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool for non-randomised studies. Fourteen independent cohorts comprising two randomised trials and 12 comparative non-randomised studies, with more than 7,400 participants overall, were included. Two randomised trials evaluated a pre-emptive 500 mL crystalloid bolus and found no reduction in peri-intubation cardiovascular collapse. Observational evidence for prophylactic vasopressors was inconsistent, with substantial changes between crude and adjusted estimates and substantial concerns regarding confounding. Studies evaluating circulation-first strategies or pre-intubation blood products generally reported associations favouring earlier circulatory resuscitation, but these findings were strongly influenced by confounding and treatment selection. Multi-component care bundles were also associated with fewer peri-intubation complications, but the independent contribution of their circulatory components could not be determined. Overall, the available evidence indicates that pre-emptive crystalloid administration does not reduce peri-intubation cardiovascular collapse, while evidence for prophylactic vasopressors, circulation-first strategies, and multi-component interventions remains insufficient to support routine use. Further randomised trials are needed, particularly among physiologically high-risk adults.
SN - 2168-8184
ER -