Crystalloid resuscitation in trauma patients: deleterious effect of 5L or more in the first 24h

Abstract

BackgroundOver-aggressive intravenous fluid therapy with crystalloids has adverse effects in trauma patients. We assessed the role of large-volume (≥5l) administration of crystalloids within 24h of injury as an independent risk-factor for mortality, in-hospital complications, and prolonged mechanical ventilation.MethodsA retrospective cohort analysis of adult trauma patients admitted to a level 1-trauma center between December 2011 and December 2012. Patient demographics, clinical and laboratory values, and total resuscitation fluid administered within the first 24h of injury were obtained. Outcomes included mortality, in-hospital complications and ventilator-days. Multivariable logistic regression and Poisson regression analyses were performed to investigate any association between the administration of ≥5L crystalloids with the aforementioned outcomes while controlling for selected clinical variables.ResultsA total of 970 patients were included in the analysis. 264 (27%) received ≥5L of crystalloids in the first 24h of injury. 118 (12%) had in-hospital complications and 337 (35%) required mechanical ventilation. The median age was 46 years (interquartile range (IQR) 27–65) years and 73% (n = 708) were males. The median injury severity score (ISS) was 17 (IQR 9–25). Overall mortality rate was 7% (n = 67). Multivariable logistic regression analysis showed several variables independently associated with mortality (p < 0.05), including resuscitation with ≥5L crystalloid in the first 24h (adjusted odds ratio (aOR) 2.55), older age (aOR 1.03), higher ISS (aOR 1.09), and lower temperature (aOR 0.68). The variables independently associated with in-hospital complications (p < 0.05) were older age, longer ICU stay, and platelet transfusion within 24h of the injury. Need for mechanical ventilation was more common in patients who received ≥5L crystalloids (RR 2.31) had higher ISS (RR 1.02), developed in-hospital complications (RR 1.91) and had lower presenting temperature (RR 0.87).ConclusionLarge-volume crystalloid resuscitation is associated with increased mortality and longer time ventilated, but not with in-hospital complications such as pneumonia and sepsis. Based on this data, we recommend judicious use of crystalloids in the resuscitation of trauma patients.

Dilemma of crystalloid resuscitation in non-exsanguinating polytrauma: what is too much?

“…In this study, up to 10 L of crystalloids < 24 hours did not seem to increase MODS and mortality whereas 5 L crystalloids < 24 hours appeared to be a cut-off point for a doubling in infectious complications and ARDS, although the incidence of ARDS was likely too small to draw any conclusions. Jones et al 33 previously also demonstrated that >5 L of crystalloids < 24 hours was associated with adverse outcomes, although results are not fully comparable since patients in their study were less severely injured.…”

“…In total, 367 patients (70% male) with a median age of 46 (28-61) years who were admitted to ICU and survived 48 hours were included. Ninety-six percent of injuries were caused by a blunt mechanism and median ISS was 29 (22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35) with most severe injuries located in the brain (AIS head 3 (1-3)) and chest (AIS chest 3 (2-4)). Eighty-six patients (23%) underwent an urgent laparotomy (table 1).…”

“…Thirty-seven (10%) patients received massive transfusion (≥10 PRBCs <24 hours, table 1). Median ISS in these massively transfused patients was 34 (27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41). SBP in ED was 84 (75-112) mm Hg, 22 (59%) of them presented with SBP <90 mm Hg and 21 (57%) patients underwent an urgent laparotomy.…”

“…In this study, up to 10 L of crystalloids <24 hours did not seem to increase MODS and mortality whereas 5 L crystalloids <24 hours appeared to be a cut-off point for a doubling in infectious complications and ARDS, although the incidence of ARDS was likely too small to draw any conclusions. Jones et al 33 previously also demonstrated that >5 L of crystalloids <24 hours was associated with adverse outcomes, A few decades ago, restriction of crystalloid fluid volume before hemorrhage control with permissive hypotension was introduced in exsanguinating patients with penetrating trauma. 1 Even though outcomes in this population were good, there is still no evidence of these concepts being successfully applied to the management of patients following blunt injury or those with TBI.…”

Trauma Resuscitation for Interventional Radiologists

“…In recent years, the trauma community has moved away from standardized crystalloid administration, as crystalloids worsen coagulopathy and increase mortality. 7,8 A balanced transfusion, with near-equal amounts of red blood cells, plasma, and platelets, should be used whenever possible to reduce the risk of coagulopathy. A 1:1:1 transfusion approach of 6 units of red blood cells, 6 units of fresh frozen plasma, and one 6-pack of platelets has been shown to decrease the risk of death from bleeding in the first 24 hours after trauma.…”