• 
• 

Three Part Question

In [adult patients presenting to the Emergency Department with penetrating chest injury] does [restrictive fluid resuscitation] affect [mortality]?

Clinical Scenario

A 42-year-old man is brought to the ED with a single stab wound to the left lateral aspect of his chest and a systolic blood pressure of 85 mmHg. He is alert, well perfused and anxious but talking to you. Appropriate management is underway to stabilise his condition; should this include early restrictive intravenous fluid resuscitation prior to definitive surgical intervention?

Search Strategy

Medline via PubMed interface searched Week 2 March 2014:
{[(penetrating OR sharp) AND (chest OR torso OR truncal)] AND [(injury OR trauma)] AND [(fluid*)]}
Search limited to Adult, Humans and English Language.

EMBASE, last searched Week 3 February 2014:
{[(exp Thorax Penetrating Trauma/)] AND [(exp Intravenous Administration/ OR (exp Liquid/)]}
Search limited to Adult, Humans and English Language

Cochrane Library, last search Week 2 April 2014:
MeSH and search words: “Thoracic Injuries” and “Fluid”

Search Outcome

Search outcome
Medline:
143 papers were identified, of which 3 were retained after abstract review.

Cochrane:
No further relevant papers identified.

EMBASE:
No relevant papers identified.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bickell WH et al, 1994, USA	598 adults with penetrating torso injuries with sBP ≤90mmHg. 309 randomised for immediate fluid resuscitation and 289 for delayed fluid resuscitation	Prospective randomised controlled trial, 1b	Survival to discharge	62% IFR vs. 70% DFR, (p=0.04)	Not blinded, randomisation determined by day of presentation Injuries not limited to thoracic region 22 patients from delayed fluid group given fluids in violation of study protocol. 471 patients excluded after randomisation for injuries deemed too severe or too minor.
			Estimated peri-operative blood loss	Average 3127mls IFR vs. 2555mls DFR, (p=0.11)
			Length of hospital stay	Average 14 days IFR vs. 11 days DFR, (p= 0.006)
			Length of ICU stay	Average 8 days IFR vs. 7 days DFR, (p=0.30)
			Post-operative complications	30% patients had ≥1 complication in IFR vs 23% in DFR, (p=0.08)
Wade CE et al, 2003, USA	230 adults with penetrating torso wounds and sBP ≤90mmHg. 120 received 250ml HSD as initial fluid therapy, 110 received 250ml 0.9% normal saline as initial fluid therapy. Subset of 100 of above 230 patients requiring surgery. 51 initially given 250ml HSD, 49 initially given 250ml 0.9% normal saline. Compared with results of 289 patients receiving delayed fluid resuscitation in below study (Bickell et al).	Analysis of data from a previous RCT1 Comparison of subsets of 2 RCTs1,2, 2b	Survival to discharge from hospital.	HSD group 82.5% survived until discharge from hospital, compared with 75.5% of normal saline group (p= 0.189)	Only the initial 250ml of fluid given was the study fluid. Patient follow-up ≤30 days Side effects / complications unclear Results for subsets not explicitly presented
			Survival to discharge from hospital.	HSD group 84.3%, normal saline group 67.4%, (p=0.047)
Duke MD et al, 2012, USA	307 adult patients with penetrating torso injuries and sBP ≤90 mm Hg managed with DCR and DCS. 132 received restrictive fluid resuscitation and 175 received standard fluid resuscitation.	Retrospective cohort, 2b	Hospital length of stay	13 ± 15 days (RFR) versus 18 ± 31 days (SFR) (p=0.02)	Amount of fluid was left to clinician discretion. Exclusion criteria may have biased results.
			Operating room mortality	9% (RFR) versus 32% (SFR) (p=0.001)
			Trauma Intensive Care Unit mortality	12% (RFR) versus 5% (SFR) (p=0.03)
			Overall mortality	21% (RFR) vs. 37% (SFR) (p=0.01)

Comment(s)

The question of quantity, type, rate and timing of intravenous fluids in penetrating chest injury is a long-standing debate and there is currently paucity of well-designed trials.

The randomised controlled trial by Bickell2 showed that delayed fluids are associated with better clinical outcomes than immediate fluid resuscitation. However the study was not limited to penetrating thoracic injuries exclusively. It is therefore difficult to generalise the results to all patients with penetrating chest trauma, particularly those with longer transfer times.

Contrary to this, Wade et al.4 suggested that aggressive fluid treatment in patients with hypotension improves survival and may be superior to delayed resuscitation. This is based on the comparison between two extremely heterogeneous groups. No data is given to show whether these groups were comparable at baseline, and the survival rates were not subjected to any further statistical analysis.

More recently Duke et al6 have shown that patients in their cohort who received less intravenous fluid prior to surgical control of haemorrhage had lower overall and operating room mortality rates, and shorter hospital stays. While there were some limitations to this study, this paper is suggestive that limited fluid resuscitation is of benefit. The question as to amount and timing of fluids given remains; there was a large difference in amounts of fluid given between the two groups. Once again, external validity issues make it difficult to generalise the results of this study as those patients who had died in the Emergency Department were excluded from analysis.

Many commentaries advocate that current best practice is permissive hypotensive resuscitation, titrating small aliquots of fluid against clinical response 2,5 but this remains mostly level 5 evidence.

Editor Comment

DCR, Damage Control Resuscitation; DCS, Damage Control Surgery; HSD, hypertonic saline dextran (7.5% NaCl/6% dextran 70); ICU, intensive care unit; sBP, systolic blood pressure; DFR, Delayed Fluid Resuscitation; IFR, Immediate Fluid Resuscitation; RFR, Restrictive Fluid Resuscitation

Clinical Bottom Line

There is limited available evidence pertaining directly to the use of fluids in penetrating thoracic injury. In comparison to delayed or limited fluid resuscitation, early aggressive fluid resuscitation of adults with penetrating torso trauma appears to be detrimental to patient outcome. There is however no evidence as to whether small aliquots of fluid titrated to clinical response or withholding all fluid resuscitation until operative management is preferable. Pending further research, expert consensus guidelines should be followed with judicious use of fluids3.

References

1. Mattox KL, Maningas PA, Moore EE, et al. Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension: the U.S.A. Multicenter Trial. Ann Surg. 1991 1991: 213; 482-491.
2. 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 27; 331: 1105-1109.
3. Greaves I, Porter KM, Revell MP. Fluid resuscitation in pre-hospital trauma care: a consensus view. J R Coll Surg Edinb 2002; 47: 451-457.
4. Wade CE, Grady JJ, Kramer GC. . fficacy of hypertonic saline dextran fluid resuscitation for patients with hypotension from penetrating trauma. J Trauma 2003; 54: S144-148.
5. Søreide E, Deakin CD. Pre-hospital fluid therapy in the critically injured patient – a clinical update. Injury 2005: 36; 1001-1010.
6. Duke MD, Guidry C, Guice J et al. Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation. J Trauma Acute Care Surg 2012; 73: 674-8.