Date Published: February 12, 2018
Publisher: John Wiley and Sons Inc.
Author(s): Shigenari Matsuyama, Ryusuke Miki, Hirotada Kittaka, Haruki Nakayama, Shota Kikuta, Satoshi Ishihara, Shinichi Nakayama.
In recent years, with the concept of damage control resuscitation, hemostasis and preoperative fluid restriction have been carried out, but there is controversy regarding the effectiveness of fluid restriction.
From April 2007 to March 2013, 101 trauma patients presented with hemorrhagic shock (systolic blood pressure ≤90 mmHg) at the prehospital or emergency department and were admitted to Hyogo Emergency Medical Center (Hyogo, Japan). They underwent emergency hemostasis by surgery and transcatheter arterial embolization. We compared two groups in a historical cohort study, the aggressive fluid resuscitation (AR) group, which included 59 cases treated in the period April 2007–March 2010, and the fluid restriction (FR) group, which included 42 cases treated in the period April 2010–March 2013.
There was no difference between both groups in patient background (heart rate, 110 b.p.m.; systolic blood pressure, 70 mmHg). The Injury Severity Score was 34 (AR) versus 38 (FR) (not significant). Preoperative infusion volume of crystalloid significantly decreased, from 2310 mL (AR) to 1025 mL (FR) (P ≤ 0.01). There was no difference in mortality (36% [AR] versus 41% [FR]). Ventilator days significantly decreased, from 8.5 days (AR) to 5.5 days (FR) (P = 0.02).
Preoperative fluid restriction for trauma patients with hemorrhagic shock did not improve mortality, but it decreased ventilator days by reducing the perioperative plus water balance and it might contribute to perioperative intensive care.
Aggressive fluid resuscitation with rapid infusion of 1,000–2,000 mL crystalloid solution is widely used for diagnostic treatment of patients with hemorrhagic shock, as recommended by the Advanced Trauma Life Support (ATLS) guidelines. The addition of a prehospital medical transport system (ambulance or helicopter with physician) greatly expands the opportunities for aggressive fluid resuscitation.
Of 2,546 trauma patients transported to our center between April 2007 and March 2013, 2,109 were direct admissions. Transfer cases that were inappropriate for the preoperative infusion volume study were excluded. Four hundred and five cases had hemorrhagic shock and systolic blood pressure ≤90 mmHg at the time of initial evaluation. After excluding patients with cardiopulmonary arrest, 101 cases that underwent emergency surgery for hemostasis remained.
Age and sex were not significantly different between the two groups. The average heart rate was 110 b.p.m. and average systolic blood pressure was 70 mmHg in both groups. The primary cause of injury was blunt trauma in both groups. The Injury Severity Score (ISS) was 34 in the AR group and 38 in the FR group. Head injuries were present in 19% of the AR group and 24% of the FR group, showing no significant difference. Hemostasis was undertaken using surgery alone, surgery and transcatheter arterial embolization (TAE), or TAE alone, with no significant difference between groups (Table 1).
Our center specializes in managing severe emergency cases and receives 1,000 cases annually. Half of these are trauma patients, and half of these have severe trauma with an ISS ≥16. The injury observation cases during the study period included 2,546 cases, of which 101 cases of emergency hemostasis were the worst. The ISS for the AR group was 34 and that for the FR group was 38, with mortality rates of 36% and 41%, respectively. The ISS in a recent report that supports fluid restriction was 18–41, with a mortality rate of 9–30%,4, 5, 6, 7 so it can be considered that our cases were severe cases of the same or higher class.
Although preoperative fluid restriction did not improve mortality in patients with hemorrhagic shock, the number of ventilator days were reduced by decreasing the perioperative plus water balance and contributing to acute intensive care.
This study protocol was approved by the ethical committee of Hyogo Emergency Medical Center (ID: 2017009).