Kwan I, Bunn F, Roberts I
Department of Paediatric Epidemiology and Biostatistics, Institute of Child Health, 30 Guilford Street, London, UK, WC1N 1EH.
Cochrane Database Syst Rev. 2001(1):CD002245. doi: 10.1002/14651858.CD002245.
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.
To assess the effects of early versus delayed, and larger versus smaller volume of fluid administration in trauma patients with bleeding.
We searched the Cochrane Controlled Trials Register, the specialised register of the Injuries Group, MEDLINE, EMBASE, the National Research Register and the Science Citation Index. We checked reference lists of identified articles and contacted authors and experts in the field.
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.
Two reviewers independently extracted data and assessed trial quality.
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=99) RR for death with a high (100 mm Hg) compared to low (70 mm Hg) systolic blood pressure resuscitation target was 1.02 (95% CI 0.27-3.85). In the third trial (n=25) there were no deaths.
REVIEWER'S CONCLUSIONS: We found no evidence from randomised controlled trials to support 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.
失血性休克的治疗包括维持血压和组织灌注直至出血得到控制。不同的复苏策略已被用于维持创伤患者的血压直至出血得到控制。然而，虽然维持血压可能预防休克，但可能会加重出血。
评估早期与延迟、大量与小量液体输注对创伤出血患者的影响。
我们检索了Cochrane对照试验注册库、伤害组专业注册库、MEDLINE、EMBASE、国家研究注册库和科学引文索引。我们检查了已识别文章的参考文献列表，并联系了该领域的作者和专家。
关于创伤出血患者静脉输液时间和量的随机试验。比较不同类型静脉输液的试验被排除。
两名评价员独立提取数据并评估试验质量。
由于干预措施和患者群体差异很大，我们没有对结果进行定量合并。早期与延迟液体输注：三项试验报告了死亡率，两项试验报告了凝血数据。在第一项试验（n = 598）中，早期液体输注的死亡相对风险（RR）为1.26（95%置信区间为1.00 - 1.58）。凝血酶原时间和活化部分凝血活酶时间的加权平均差（WMD）分别为2.7（95% CI 0.9 - 4.5）秒和4.3（95% CI 1.74 - 6.9）秒。在第二项试验（n = 50）中，早期输血的死亡RR为5.4（95% CI 0.3 - 107.1）。活化部分凝血活酶时间的WMD为7.0（95% CI 6.0 - 8.0）秒。在第三项试验（n = 1309）中，早期液体输注的死亡RR为1.06（95% CI 0.77 - 1.47）。大量与小量液体输注：三项试验报告了死亡率，一项试验报告了凝血数据。在第一项试验（n = 36）中，大量液体复苏的死亡RR为0.80（95% CI 0.28 - 22.29）。接受大量液体输注者的凝血酶原时间和活化部分凝血活酶时间分别为14.8秒和47.3秒，而对照组分别为13.9秒和35.1秒。在第二项试验（n = 99）中，收缩压复苏目标为高（100 mmHg）与低（70 mmHg）时的死亡RR为1.02（95% CI 0.27 - 3.85）。在第三项试验（n = 25）中无死亡病例。
我们未从随机对照试验中找到证据支持在未控制的出血中早期或大量静脉输液。对于出血创伤患者的最佳液体输注策略仍存在不确定性。需要进一步的随机对照试验来确定最有效的液体复苏策略。
