Timing and volume of fluid administration for patients with bleeding

Abstract

Background: Treatment of haemorrhagic shock involves maintaining blood pressure and tissue perfusion until bleeding is controlled. Different resuscitation strategies have been used to maintain the blood pressure in trauma patients until bleeding is controlled. However, while maintaining blood pressure may prevent shock, it may worsen bleeding. Objectives: To assess the effects of early versus delayed, and larger versus smaller volume of fluid administration in trauma patients with bleeding. Search strategy: We searched the CENTRAL (The Cochrane Library 2008, Issue 4), the Cochrane Injuries Group's Specialised Register (searched October 2008), MEDLINE (to October 2008), EMBASE (to October 2008), the National Research Register (in Current controlled trials.gov; searched October 2008) and the Science Citation Index (to October 2008). We checked reference lists of identified articles and contacted authors and experts in the field. Selection criteria: Randomised trials of the timing and volume of intravenous fluid administration in trauma patients with bleeding. Trials in which different types of intravenous fluid were compared were excluded. Data collection and analysis: Two authors independently extracted data and assessed trial quality. Main results: We did not combine the results quantitatively because the interventions and patient populations were so diverse. Early versus delayed fluid administration Three trials reported mortality and two coagulation data. In the first trial (n=598) relative risk (RR) for death with early fluid administration was 1.26 (95% confidence interval of 1.00−1.58). The weighted mean differences (WMD) for prothrombin time and partial thromboplastin time were 2.7 (95% CI 0.9−4.5) and 4.3 (95% CI 1.74−6.9) seconds respectively. In the second trial (n=50) RR for death with early blood transfusion was 5.4 (95% CI 0.3−107.1). The WMD for partial thromboplastin time was 7.0 (95% CI 6.0−8.0) seconds. In the third trial (n=1309) RR for death with early fluid administration was 1.06 (95% CI 0.77−1.47). Larger versus smaller volume of fluid administration Three trials reported mortality and one coagulation data. In the first trial (n=36) RR for death with a larger volume of fluid resuscitation was 0.80 (95% CI 0.28−22.29). Prothrombin time and partial thromboplastin time were 14.8 and 47.3 seconds in those who received a larger volume of fluid, as compared to 13.9 and 35.1 seconds in the comparison group. In the second trial (n=110) RR for death with a high systolic blood pressure resuscitation target (100mmHg) maintained with a larger volume of fluid, as compared to low systolic blood pressure resuscitation target (70mmHg) maintained with a smaller volume of fluid was 1.00 (95% CI 0.26−3.81). In the third trial (n=25) there were no deaths. Authors' conclusions: We found no evidence from randomised controlled trials for or against early or larger volume of intravenous fluid administration in uncontrolled haemorrhage. There is continuing uncertainty about the best fluid administration strategy in bleeding trauma patients. Further randomised controlled trials are needed to establish the most effective fluid resuscitation strategy.