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

References

Retrieved from "https://www.wikem.org/w/index.php?title=EBQ:Delayed_Fluid_Resuscitation_in_Trauma&oldid=388439"