EBQ:Delayed Fluid Resuscitation in Trauma

Complete Journal Club Article

Bickell WH, Wall MJ Jr, Pepe PE, et al.. "Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries". N Engl J Med. 1994. 331(17):1105-1109.
PubMed Full text

Clinical Question

Does delaying aggressive fluid resuscitation until operative intervention improve survival in hypotensive patients with penetrating torso injuries?

Conclusion

• Delayed fluid resuscitation until operative intervention was associated with improved survival and fewer complications in hypotensive patients with penetrating torso injuries
• Immediate resuscitation may worsen hemorrhage by increasing blood pressure before surgical control of bleeding

Major Points

• This was a landmark study that challenged the standard practice of aggressive prehospital and ED fluid resuscitation in trauma
• Survival was significantly higher in the delayed resuscitation group (70% vs 62%, p=0.04)
• Delayed resuscitation was associated with shorter hospital stays and fewer complications (ARDS, renal failure, coagulopathy, wound infection)
• The concept of "permissive hypotension" in trauma resuscitation was largely influenced by this study
• Results were specific to penetrating torso trauma in an urban setting with short transport times

Study Design

• Prospective, controlled clinical trial
• Single center: Ben Taub General Hospital, Houston, Texas
• N = 598 adult patients with penetrating torso injuries and prehospital SBP <=90 mmHg
• Study period: 1990-1993
• Primary Outcome: survival to hospital discharge

Population

Patient Demographics

• Mean age: 31 years
• Male: 96%
• Gunshot wounds: 59%, Stab wounds: 41%
• Mean prehospital SBP: 72 mmHg (immediate) vs 79 mmHg (delayed)

Inclusion Criteria

• Age >=16 years
• Penetrating torso injury
• Prehospital SBP <=90 mmHg

Exclusion Criteria

• GCS <=8 (isolated head injury)
• Transfer from another facility
• Transport time >30 minutes

Interventions

• Immediate resuscitation group (n=309): Standard IV fluid resuscitation beginning in the prehospital setting and continuing in the ED
• Delayed resuscitation group (n=289): IV access obtained but fluids withheld until patient was in the operating room
• Both groups received standard surgical management

Outcomes

Primary Outcome

• Survival to hospital discharge:
  • Delayed resuscitation: 203/289 (70%)
  • Immediate resuscitation: 193/309 (62%)
  • p = 0.04

Secondary Outcomes

• Postoperative complications were lower in the delayed group:
  • ARDS: 2% vs 7%
  • Acute renal failure: 1% vs 4%
  • Coagulopathy: 1% vs 4%
  • Wound infection: 5% vs 11%
• Shorter hospital stay in delayed group: 11 vs 14 days

Criticisms

• Not a true randomized trial; allocation was based on alternating days, which may introduce bias
• Single-center study in an urban trauma center with short transport times; may not apply to rural settings
• Only included penetrating trauma; results should not be extrapolated to blunt trauma
• Baseline differences between groups (injury severity, mechanism) may have confounded results
• The study has never been replicated in a true randomized fashion due to ethical concerns
• Concept of permissive hypotension has been broadened well beyond the original study population

Funding

• None reported

See Also

• Trauma resuscitation
• Hemorrhagic shock
• Damage control resuscitation