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

Abstract

BackgroundAggressive crystalloid resuscitation increases morbidity and mortality in exsanguinating patients. Polytrauma patients with severe tissue injury and subsequent inflammatory response without major blood loss also need resuscitation. This study investigated crystalloid and blood product resuscitation in non-exsanguinating polytrauma patients and studied possible adverse outcomes.MethodsA 6.5-year prospective cohort study included consecutive trauma patients admitted to a Level 1 Trauma Center intensive care unit (ICU) who survived 48 hours. Demographics, physiologic and resuscitation parameters in first 24 hours, Denver Multiple Organ Failure scores, adult respiratory distress syndrome (ARDS) data and infectious complications were prospectively collected. Patients were divided in 5 L crystalloid volume subgroups (0–5, 5–10, 10–15 and >15 L) to make clinically relevant comparisons. Data are presented as median (IQR); p value <0.05 was considered significant.Results367 patients (70% men) were included with median age of 46 (28–61) years, median Injury Severity Score was 29 (22–35) and 95% sustained blunt injuries. 17% developed multiple organ dysfunction syndrome (MODS), 4% ARDS and 14% died. Increasing injury severity, acidosis and coagulopathy were associated with more crystalloid administration. Increasing crystalloid volumes were associated with more blood products, increased ventilator days, ICU length of stay, hospital length of stay, MODS, infectious complications and mortality rates. Urgent laparotomy was found to be the most important independent predictor for crystalloid resuscitation in multinominal regression analysis. Further, fresh frozen plasma (FFP) <8 hours was less likely to be administered in patients >5 L compared with the group 0–5 L. With increasing crystalloid volume, the adjusted odds of MODS, ARDS and infectious complications increased 3–4-fold, although not statistically significant. Mortality increased 6-fold in patients who received >15 L crystalloids (p=0.03).DiscussionPolytrauma patients received large amounts of crystalloids with few FFPs <24 hours. In patients with <10 L crystalloids, <24-hour mortality and MODS rates were not influenced by crystalloid resuscitation. Mortality increased 6-fold in patients who received >15 L crystalloids ≤24 hours. Efforts should be made to balance resuscitation with modest crystalloids and sufficient amount of FFPs.Level of evidenceLevel 3.Study typePopulation-based cohort study.

Early correction of base deficit decreases late mortality in polytrauma

“…1. Ninety-one percent of injuries (n = 213) were caused by a blunt mechanism and median Injury Severity Score (ISS) was 33 (24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38) with most severe injuries located in the brain (AIS head 3 (0-4)) and chest (AIS chest 3 (2-4)). Physiology, resuscitation, and outcome data are presented in Table 1.…”

“…This is confirmed by the fact that crystalloids < 24 h were an independent predictor for mortality. Additionally, we have demonstrated in a previous study that large amounts of crystalloids are known to attribute to increased mortality [ 32 ]. Crystalloid administration < 24 h does not fully explain the differences in AUC between surviving and deceased patients since AUC was measured until base deficit normalization or up to 48 h, and BD was again within normal limits < 48 h in both groups.…”

Impact of Fluid Balance on Intensive Care Unit Length of Stay in Critically Ill Trauma Patients

“…1,2 Prospective data have suggested increased mortality in patients who receive more than 15 L of crystalloids within 24 hours of hospital presentation. 3 An even larger prospective review suggested that administration of more than 1.5 L of fluid is correlated with increased mortality. 4 A review of 1754 patients from the Glue Grant Database suggested that larger volumes of crystalloid administered within the first 24 hours after injury were correlated with more ventilator days, longer intensive care unit (ICU) and hospital length of stay, and higher rates of acute respiratory distress syndrome (ARDS), multi-organ failure, compartment syndromes, and infectious complications.…”

Optimization of Patients Outcomes: Management Strategies for Polytrauma in the Neuro-ICU

“…However, in some cases it may be more useful to administer plasma instead, to prevent acute respiratory distress syndrome or multiple organ dysfunction syndrome. 15 18) In addition, hemodynamic monitoring (e.g., stroke volume and pulse pressure variations) is recommended to evaluate the reactivity of fluid management. 11) …”