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Three Part Question

In [adults with a ruptured abdominal aortic aneurysm] is [pre-operative intravenous fluid resuscitation more effective than withholding fluids] at [improving early and late survival rates]?

Clinical Scenario

A 75 year old man presents to the Emergency department after collapsing at home with a sudden onset of back pain. On examination he is fully conscious, distressed with pain and has an expansile pulsating epigastric mass. His blood pressure is 80/40 mmHg. While you are waiting for the surgical consult you wonder whether it would be worthwhile administering a large I/V fluid bolus. This should raise his BP and may improve his tissue oxygen delivery. However, it may also increase bleeding from the aneurysm and will dilute clotting factors.

Search Strategy

Medline 1966-10/98 using the OVID interface.
[exp aortic aneurysm OR aortic aneurysm ti.ab.sh.] AND [exp resuscitation OR resuscitation ti.ab.sh.] LIMIT to human and english language.

Search Outcome

122 papers were found, of which 115 were irrelevant or of insufficient quality to include. No single studies directly address the 3 part question. The 7 closest studies are shown below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ouriel K et al, 1990, USA	243 patients operated on with ruptured AAA	Retrospective study	Death within 30 days of operation	Overall model (MLR) showed initial low SBP<70, COPD, CRF and a non-vascular surgeon to be independent predictors	Amount of pre-op fluid has not been analyzed as a separate factor Analysis mainly of pre-op, pre-morbid type of surgeon and hospital factors
Aburahma AF et al, 1991, USA	73 patients operated on with ruptured AAA	Retrospective study	Death within 30 days of operation	Overall model (MLR) showed type of rupture; intra vs retroperitoneal to be only independent predictor	Amount of pre-op fluid has not been analyzed as a separate factor Pre-op factors, syncope, HB, BP and total blood loss or transfusions only significant when type of rupture not adjusted for
Johansen K et al, 1991, USA	186 patients with ruptured AAA	Retrospective study	Pre-op death or death within 30 days of op	Pre-op cardiac arrest, age>80, female gender. Pre-op SBP <90mmHg or HCT <25% and total peri-op transfusions >15 associated with death	No MLR performed Pre-op fluids not a separate factor
Gloviczki P et al, 1992, USA	231 patients operated on with ruptured AAA	Retrospective study	Death within 30 days of operation	Overall model (MLR) showed high APACHE II, initial low H/crit, SBP<90 and COPD to be independent predictors	Amount of pre-op fluid has not been analyzed as a separate factor Analysis mainly of pre-op and pre-morbid factors
Brimacombe J and Berry A, 1994, Australia	Patients with ruptured AAA	Review article. 112 total articles, about 10 specifically related to fluid resus.	Peri-operative mortality	Found no PRCTs, only retrospective work	Thought balance of evidence in conscious patients favoured minimal fluid with early surgery
Chen JC et al, 1996, Canada	478 patients undergoing abdominal aortic aneurysm (AAA) surgery. 157 ruptured	Retrospective study. Ruptures analyzed separately.	Pre-op death or death within 30 days of operation	Pre-op model (MLR) showed age, conscious level and cardiac arrest to be independent predictors	Amount of pre-op fluid does not seem to have been analyzed as a separate factor
Farooq MM et al, 1996, USA	122 patients with ruptured AAA	Retrospective study	Total mortality and complications	Death associated with hypotension, short pre-surgical times and total transfusion required	No MLR performed Pre-op fluids not a separate factor

Comment(s)

No study appears to have addressed this specific question by valid statistical analysis. Current practice is clearly opinion based and at least a decent retrospective review is indicated.

Clinical Bottom Line

Further research needs to be conducted into this area.

References

1. Ouriel K, Geary K, Green RM, et al. Factors determining survival after ruptured aortic aneurysm: the hospital, the surgeon, and the patient. J Vasc Surg 1990;11(4):493-6.
2. Aburahma AF, Woodruff BA, Lucente FC, et al. Factors affecting survival of patients with ruptured abdominal aortic aneurysm in a West Virginia community. Surgery, Gynecology & Obstetrics 1991;172:377-82.
3. Johansen K, Kohler TR, Nicholls SC, et al. Ruptured abdominal aortic aneurysm: the Harborview experience. J Vasc Surg 1991:13(2):240-5.
4. Gloviczki P, Pairolero PC, Mucha P Jr., et al. Ruptured abdominal aortic aneurysms: repair should not be denied. J Vasc Surg 1992;15(5):851-7.
5. Brimacombe J, Berry A. Haemodynamic management in ruptured abdominal aortic aneurysm. Postgrad Med J 1994;70(822):252-6.
6. Chen JC, Hildebrand HD, Salvian AJ, et al. Predictors of death in nonruptured and ruptured abdominal aortic aneurysms. J Vasc Surg 1996;24(4):614-20.
7. Farooq MM, Freischlag JA, Seabrook GR, et al. Effect of the duration of symptoms, transport time, and length of emergency room stay on morbidity and mortality in patients with ruptured abdominal aortic aneurysms. Surgery 1996;119(1):9-14.