Clinical effectiveness and cost-effectiveness of prehospital intravenous fluids in trauma patients

Prehospital hypertonic fluid resuscitation for trauma patients: A systematic review and meta-analysis

BACKGROUND

Prehospital assessment of a patient's circulation status and appropriate resuscitation with intravenous fluids plays a critical role in patients with obvious hemorrhage or systolic blood pressure below 90 mm Hg.

OBJECTIVES

We assessed the efficacy and safety of prehospital administration of crystalloids or colloids to improve the survival rate of trauma patients with acceptable safety profile.

DATA SOURCES

We searched SCOPUS, Embase, TRIP database, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and PubMed as per search protocol from January 1, 1900 to February 12, 2015.

STUDY ELIGIBILITY CRITERIA

All randomized controlled trials were considered.

PARTICIPANTS AND INTERVENTIONS

All patients had penetrating or blunt trauma, excluding traumatic brain or thermal injuries. At least one of the comparators should be a crystalloid or colloid.

STUDY APPRAISAL AND SYNTHESIS METHODS

Detailed search strategy was developed and utilized. Duplicates were removed from the search results. We, the co-first authors (C.d.C. and F.G.), independently reviewed the article titles and abstracts to assess eligibility. Eligible articles were downloaded for full text review to determine inclusion in the review and analysis. We (C.d.C. and F.G.) performed a methodological quality assessment of each included article. The primary outcome was mortality. The secondary outcomes included adverse events, infections, multiple organ dysfunction score, and length of stay at the hospital. Heterogeneity was measured by I value. An I value greater than 50% was considered to be substantial heterogeneity. Fixed effect analysis and random effect analysis were performed when needed.

RESULTS

A total of nine trials (3,490 patients) were included in the systematic review, and six trials were included in meta-analyses. There were no significant differences between hypertonic saline with dextran and lactated Ringer's solution in 1 day using two studies (2.91; 95% CI, 0.58-14.54; p = 0.19) and 28- to 30-day survival rates using another two studies (1.47; 95% CI, 0.30-7.18; p = 0.63). Adding dextran to hypertonic saline did not increase the survival rate (0.94; 95% CI, 0.65-1.34; p = 0.71). Overall, complications were comparable between all groups.

LIMITATIONS

The quality of some of the included studies is not optimal.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

There is no beneficial effect of hypertonic saline with or without dextran in general traumatic patients. Further trials to evaluate its benefit in patients with penetrating trauma requiring surgery are warranted.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level I.

Resuscitation fluids in trauma 1: why give fluid and how to give it

Fluid resuscitation following trauma is necessary to restore compromised organ perfusion and hypoxic tissue damage. The activation of the Systemic Inflammatory Response Syndrome in response to both traumatic and subsequent hypoxic insults has implications for what represents the optimal fluid resuscitation strategy. There is no single resuscitation strategy that can be applied to all patients with traumatic injury. This article reviews the evidence available to help guide fluid therapy.

A number of studies have suggested that timing of fluid therapy with respect to surgical intervention is crucial. Prior to definitive treatment of injury permissive hypotension confers advantage, particularly in the setting of penetrating trauma. The situation is less clear in cases of blunt trauma, where further studies comparing restrictive with liberal fluid regimes are required. The site of injury will also influence the strategy to be adopted. Following traumatic brain injury, maintenance of cerebral perfusion pressure is likely to be of overriding importance.

Once definitive surgical control of haemorrhage has been achieved, fluid therapy to maximise stroke volume and cardiac output is advised. Following the development of established critical illness, goal-directed therapy may increase mortality.

Is there a place for crystalloids and colloids in remote damage control resuscitation?

Crystalloids and colloids are used in prehospital fluid resuscitation to replace blood loss and preserve tissue perfusion until definite surgical control of bleeding can be achieved. However, large volumes of fluids will increase bleeding by elevating blood pressure, dislodging blood clots, and diluting coagulation factors and platelets. Hypotensive fluid resuscitation strategies are used to avoid worsening of uncontrolled bleeding. This is largely supported by animal studies. Most clinical evidence suggests that restricting fluid therapy is associated with improved outcome. Remote damage control resuscitation emphasizes the early use of blood products and restriction of other fluids to support coagulation and tissue oxygenation. Controversy regarding the optimal choice and composition of resuscitation fluids is ongoing. Compared with crystalloids, less colloid is needed for the same expansion of intravascular volume. On the other hand, colloids may cause coagulopathy not only related to dilution. The most important advantage of using colloids is logistical because less volume and weight are needed. In conclusion, prehospital fluid resuscitation is considered the standard of care, but there is little clinical evidence supporting the use of either crystalloids or colloids in remote damage control resuscitation. Alternative resuscitation fluids are needed.

Systematic analysis of hydroxyethyl starch (HES) reviews: proliferation of low-quality reviews overwhelms the results of well-performed meta-analyses

PURPOSE

Hydroxyethyl starch (HES) is a synthetic colloid used widely for resuscitation despite the availability of safer, less costly fluids. Numerous HES reviews have been published that may have influenced clinicians' practice. We have therefore examined the relationship between the methodological quality of published HES reviews, authors' potential conflicts of interest (pCOI) and the recommendations made.

METHODS

Systematic analysis of reviews on HES use.

RESULTS

Between 1975 and 2010, 165 reviews were published containing recommendations for or against HES use. From the 1990s onwards, favorable reviews increased from two to eight per year and HES's share of the artificial colloid market tripled from 20 to 60 %. Only 7 % (12/165) of these reviews of HES use contained meta-analyses; these 7 % had higher Overview Quality Assessment Questionnaire (OQAQ) scores [median (range) 6.5 (3-7)] than reviews without meta-analysis [2 (1-4); p < 0.001]. The rates of recommending against HES use are 83 % (10/12) in meta-analyses and 20 % (31/153) in reviews without meta-analysis (p < 0.0001). Fourteen authors published the majority (70/124) of positive reviews, and ten of these 14 had or have since developed a pCOI with various manufacturers of HES.

CONCLUSIONS

Low-quality HES reviews reached different conclusions than high-quality meta-analyses from independent entities, such as Cochrane Reviews. The majority of these low-quality positive HES reviews were written by a small group of authors, most of whom had or have since established ties to industry. The proliferation of positive HES reviews has been associated with increased utilization of an expensive therapy despite the lack of evidence for meaningful clinical benefit and increased risks. Clinicians need to be more informed that marketing efforts are potentially influencing scientific literature.

The clinical effectiveness of permissive hypotension in blunt abdominal trauma with hemorrhagic shock but without head or spine injuries or burns: a systematic review

Background

Trauma is a major cause of death and disability. The current trend in trauma management is the rapid administration of fluid as per the Advanced Trauma Life Support guidelines, although there is no evidence to support this and even some to suggest it might be harmful. Some guidelines, protocols, and recommendations have been established for the use of permissive hypotension although there is reluctance concerning its application in blunt injuries.

Objectives

The aim of this review is to determine whether there is evidence of the use of permissive hypotension in the management of hemorrhagic shock in blunt trauma patients. This review also aims to search for any reason for the reluctance to apply permissive hypotension in blunt injuries.

Methods

This systematic review has followed the steps recommended in the Cochrane Handbook for Systematic Reviews of Interventions. It is also being reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement and checklist. Database searches of MEDLINE, EMBASE, the Centre for Reviews and Dissemination databases and the Cochrane Library were made for eligible studies as well as journal searches. Inclusion criteria included systematic reviews that have similar primary questions to this review and randomized controlled trials where patients with blunt torso injuries and hemorrhagic shock were not excluded. Rapid or early fluid administration was compared with controlled or delayed fluid resuscitation and a significant outcome was obtained.

Results

No systematic reviews attempting to answer similar questions were found. Two randomized controlled trials with mixed types of injuries in the included patients found no significant difference between the groups used in each study. Data concerning the question of this review was sought after these papers were appraised.

Conclusion

The limited available data are not conclusive. However, the supportive theoretical concept and laboratory evidence do not show any reason for treating blunt injuries differently from other traumatic injuries. Moreover, permissive hypotension is being used for some nontraumatic causes of hemorrhagic shock and in theater. Therefore, this should encourage interested researchers to continue clinical work in this important field.

Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients

PURPOSE

Colloids are administered to more patients than crystalloids, although recent evidence suggests that colloids may possibly be harmful in some patients. The European Society of Intensive Care Medicine therefore assembled a task force to compile consensus recommendations based on the current best evidence for the safety and efficacy of the currently most frequently used colloids--hydroxyethyl starches (HES), gelatins and human albumin.

METHODS

Meta-analyses, systematic reviews and clinical studies of colloid use were evaluated for the treatment of volume depletion in mixed intensive care unit (ICU), cardiac surgery, head injury, sepsis and organ donor patients. Clinical endpoints included mortality, kidney function and bleeding. The relevance of concentration and dosage was also assessed. Publications from 1960 until May 2011 were included. The quality of available evidence and strength of recommendations were based on the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RECOMMENDATIONS AND CONCLUSIONS

We recommend not to use HES with molecular weight ≥ 200 kDa and/or degree of substitution >0.4 in patients with severe sepsis or risk of acute kidney injury and suggest not to use 6% HES 130/0.4 or gelatin in these populations. We recommend not to use colloids in patients with head injury and not to administer gelatins and HES in organ donors. We suggest not to use hyperoncotic solutions for fluid resuscitation. We conclude and recommend that any new colloid should be introduced into clinical practice only after its patient-important safety parameters are established.

Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis

OBJECTIVE

Prehospital intravenous (IV) fluid administration is common in trauma patients, although little evidence supports this practice. We hypothesized that trauma patients who received prehospital IV fluids have higher mortality than trauma patients who did not receive IV fluids in the prehospital setting.

METHODS

We performed a retrospective cohort study of patients from the National Trauma Data Bank. Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital IV fluid administration, using patient demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on mechanism (blunt/penetrating), hypotension, immediate surgery, severe head injury, and injury severity score.

RESULTS

A total of 776,734 patients were studied. Approximately half (49.3%) received prehospital IV. Overall mortality was 4.6%. Unadjusted mortality was significantly higher in patients receiving prehospital IV fluids (4.8% vs. 4.5%, P < 0.001). Multivariable analysis demonstrated that patients receiving IV fluids were significantly more likely to die (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05–1.17). The association was identified in nearly all subsets of trauma patients. It is especially marked in patients with penetrating mechanism (OR 1.25, 95% CI 1.08–1.45), hypotension (OR 1.44, 95% CI1.29–1.59), severe head injury (OR 1.34, 95% CI 1.17–1.54), and patients undergoing immediate surgery (OR 1.35, 95% CI 1.22–1.50).

CONCLUSIONS

The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.

Resuscitation and coagulation in the severely injured trauma patient

Developments in the resuscitation of the severely injured trauma patient in the last decade have been through the increased understanding of the early pathophysiological consequences of injury together with some observations and experiences of recent casualties of conflict. In particular, the recognition of early derangements of haemostasis with hypocoagulopathy being associated with increased mortality and morbidity and the prime importance of tissue hypoperfusion as a central driver to this process in this population of patients has led to new resuscitation strategies. These strategies have focused on haemostatic resuscitation and the development of the ideas of damage control resuscitation and damage control surgery continuum. This in turn has led to a requirement to be able to more closely monitor the physiological status, of major trauma patients, including their coagulation status, and react in an anticipatory fashion.

Guidelines for prehospital fluid resuscitation in the injured patient

Although the need and benefit of prehospital interventions has been controversial for quite some time, an increasing amount of evidence has stirred both sides into more frequent debate. Proponents of the traditional "scoop-and-run" technique argue that this approach allows a more timely transfer to definitive care facilities and limits unnecessary (and potentially harmful) procedures. However, advocates of the "stay-and-play" method point to improvement in survival to reach the hospital and better neurologic outcomes after brain injury. Given the lack of consensus, the Eastern Association for the Surgery of Trauma convened a Practice Management Guideline committee to answer the following questions regarding prehospital resuscitation: (1) should injured patients have vascular access attempted in the prehospital setting? (2) if so, what location is preferred for access? (3) if access is achieved, should intravenous fluids be administered? (4) if fluids are to be administered, which solution is preferred? and (5) if fluids are to be administered, what volume and rate should be infused?

Reperfusion injury after hemorrhage: a collective review

OBJECTIVE

To review current knowledge of hemorrhagic shock and reperfusion injury.

SUMMARY BACKGROUND DATA

Patients with hemorrhagic shock require optimal resuscitation and cessation of ongoing bleeding. Often our resuscitative measures, while necessary, cause a wide range of detrimental physiologic effects. Research continues to answer questions regarding measurable endpoints and optimal fluids used in resuscitation. Elucidation and understanding of the complex metabolic pathways involved in reperfusion injury are areas of intense current investigative effort.

METHODS

A literature review was performed using MEDLINE and key words related to experimental and clinical studies concerning shock and reperfusion.

RESULTS

Experimental studies have shown that resuscitation with colloid and crystalloid show no difference in outcomes in critically ill patients. Laboratory studies are showing promising results with immunomodulation of response to injury. However, no clinical trials have shown significance yet.

CONCLUSIONS

It is unlikely that a single treatment modality or "magic bullet" will be able to substantially block such a complex regulated process unless performed before feedback mechanisms known to be in place. Ongoing translational research will inevitably have a major impact on patient care.

Secondary abdominal compartment syndrome after severe extremity injury: are early, aggressive fluid resuscitation strategies to blame?

INTRODUCTION

Secondary abdominal compartment syndrome (ACS) is the development of ACS in the absence of abdominal injury. The development of secondary ACS has been viewed by some authors as an unavoidable sequela of the aggressive crystalloid resuscitation often employed in the treatment of severe shock. We hypothesized that poor resuscitation techniques, including early and excessive crystalloid administration, places patients with extremity injuries at risk for developing secondary ACS.

METHODS

The Trauma Registry of the American College of Surgeons database was queried for all patients with an extremity Abbreviated Injury Scale (AIS) score of 3 or greater and abdominal AIS score of 0 treated at our institution between January 1, 2001 and December 31, 2005. The study group included those patients who developed secondary ACS, whereas the comparison cohort included those who did not develop secondary ACS.

RESULTS

Forty-eight patients developed secondary ACS and were compared with 48 randomly selected patients who had an extremity AIS score of 3 or greater and an abdomen AIS score of 0. There were no differences between the groups with respect to age, sex, race, or individual AIS scores. However, the secondary ACS group had a slightly higher Injury Severity Score (25.6 vs. 21.4, p = 0.02), significantly higher operating room crystalloid administration (9.9 L vs. 2.7 L, p < 0.001), and more frequent use of a rapid infuser (12.5% vs. 0.0%, p = 0.01). Multiple logistic regression identified prehospital and emergency department crystalloid as predictors of secondary ACS.

CONCLUSIONS

Aggressive resuscitation techniques, often begun in the prehospital setting, appear to increase the likelihood of patients with severe extremity injuries developing secondary ACS. Early, large volume crystalloid administration was the greatest predictor of secondary ACS.

The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies

Increasing evidence has demonstrated that aggressive crystalloid-based resuscitation strategies are associated with cardiac and pulmonary complications, gastrointestinal dysmotility, coagulation disturbances, and immunological and inflammatory mediator dysfunction. As large volumes of fluids are administered, imbalances in intracellular and extracellular osmolarity occur. Disturbances in cell volume disrupt numerous regulatory mechanisms responsible for keeping the inflammatory cascade under control. Several authors have demonstrated the detrimental effects of large, crystalloid-based resuscitation strategies on pulmonary complications in specific surgical populations. Additionally, fluid-restrictive strategies have been associated with a decreased frequency of and shorter time to recovery from acute respiratory distress syndrome and trends toward shorter lengths of stay and lower mortality. Early resuscitation of hemorrhagic shock with predominately saline-based regimens has been associated with cardiac dysfunction and lower cardiac output, as well as higher mortality. Numerous investigators have evaluated potential risk factors for developing abdominal compartment syndrome and have universally noted the excessive use of crystalloids as the primary determinant. Resuscitation regimens that cause early increases in blood flow and pressure may result in greater hemorrhage and mortality than those regimens that yield comparable flow and pressure increases late in resuscitation. Future resuscitation research is likely to focus on improvements in fluid composition and adjuncts to administration of large volume of fluid.

Clinical practice guidelines: a critical review

PURPOSE

Clinical practice guidelines (CPGs) have been developed for many years with the aim of improving the quality of care. A review of the use of CPGs and assessments of CPG compliance among practitioners so far would aid the understanding of factors influencing CPG compliance. This study seeks to provide this.

DESIGN/METHODOLOGY/APPROACH

A general review and discussion of CPGs in areas of their attributes, benefits and pitfalls were carried out. Articles concerning the assessment of CPG compliance were also reviewed to understand the kind of data collected for such assessments (qualitative vs quantitative), the methods used to collect data (objective versus subjective), and the assessment measures employed (process versus outcome).

FINDINGS

A total of 57 CPG compliance assessment studies were reviewed. Almost two-thirds employed objective methods. Of the subjective assessments, 47 per cent analysed solely quantitative data, 32 per cent analysed solely qualitative information and 21 per cent analysed both. More than four-fifths of all studies used process measures to determine CPG compliance and only 5 per cent used solely outcome measures.

PRACTICAL IMPLICATIONS

Depending on the methods used, assessments can help identify various factors influencing CPG compliance. Such factors may be related to the physician, guidelines, health system or patient. A good understanding of these factors and their role in influencing compliance behaviour will help health regulators and administrators plan better and more effective strategies to improve doctors' CPG compliance.

ORIGINALITY/VALUE

This review looks at the various aspects of CPGs to understand how these influence practitioners' compliance.

The National EMS Research strategic plan

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

Pre-hospital fluid therapy in the critically injured patient--a clinical update

Venous access and fluid therapy should still be considered to be essential elements of pre-hospital advanced life support (ALS) in the critically injured patient. Initiation of fluid therapy should be based on a clinical assessment, most importantly the presence, or otherwise, of a radial pulse. The goal in penetrating injury is to avoid hypovolaemic cardiac arrest during transport, but at the same time not to delay transport, or increase systolic blood pressure. The goal in blunt injury is to secure safe perfusion of the injured brain through an adequate cerebral perfusion pressure, which generally requires a systolic blood pressure well above 100 mmHg. Patients without severe brain injury tolerate lower blood pressures (hypotensive resuscitation). Importantly, using systolic blood pressure targets to titrate therapy is not as easy as it seems. Automated (oscillometric) blood pressure measurement devices frequently give erroneously high values. The concept of hypotensive resuscitation has not been validated in the few studies done in humans. Hence, the suggested targeted systolic blood pressures should only provide a mental framework for the decision-making. The ideal pre-hospital fluid regimen may be a combination of an initial hypertonic solution given as a 10-20 minutes infusion, followed by crystalloids and, in some cases, artificial colloids. This review is intended to help the clinician to balance the pros and cons of fluid therapy in the individual patient.