Hébert Samuel, Kohtakangas Erica, Campbell Alanna, Ohle Robert
Northern Ontario School of Medicine, Sudbury, ON, Canada.
Health Sciences North, Sudbury, ON, Canada.
CJEM. 2023 Mar;25(3):200-208. doi: 10.1007/s43678-023-00447-9. Epub 2023 Feb 3.
The most widely used prehospital strategy for the management of hemorrhagic shock or trauma accompanied by hypotension is fluid resuscitation. Though current guidelines suggest early and aggressive fluid resuscitation, contemporary literature suggests a more restrictive approach. Our objective was to evaluate the effectiveness of low/ no IV fluids in comparison to standard resuscitation in reducing mortality for trauma patients in the prehospital setting.
Population-adults with blunt or penetrating trauma in the prehospital setting with severe injury (defined as SBP < 90 mm Hg and/or a shock index > (1). Intervention-low-dose/no IV fluids. Comparison-standard resuscitation. Outcome-mortality. A librarian-assisted search of five databases (Medline, Embase, Web of Science, and CINAHL, Cochrane trials) was completed in June 2021 (updated in November 2022). ROBINS-1 and ROB-2 tools were used to assess risk of bias in observational and randomized studies, respectively. An inverse variance method and random-effects model of statistical analysis were utilized, with data reported as risk ratios with related 95% confidence intervals. Heterogeneity of studies was assessed through analysis of the I RESULTS: Seven studies (six observational and one randomized trial) were included, with three thousand and fifty study participants included for analysis. Four studies compared high- to low-dose fluids, and three compared fluids to no fluids. We found no difference in mortality when comparing standard resuscitation to restricted resuscitation (RR 0.99, 95% CI [0.80-1.22], I = 54%).
Weak, primarily observational evidence suggests that standard fluid resuscitation has no significant mortality benefit over restricting/withholding IV fluids in severe/hypotensive trauma. This review adds evidence to questioning the requirement for IV fluids in trauma given the lack of mortality benefit, in addition to demonstrating the need for more randomized studies in this area.
对于失血性休克或伴有低血压的创伤，院前最广泛使用的治疗策略是液体复苏。尽管当前指南建议早期积极进行液体复苏，但当代文献提出了一种更为限制性的方法。我们的目的是评估与标准复苏相比，低剂量/不进行静脉输液在降低院前创伤患者死亡率方面的有效性。
研究对象为院前钝性或穿透性创伤的成年重症患者（定义为收缩压<90 mmHg和/或休克指数>1）。干预措施为低剂量/不进行静脉输液。对照为标准复苏。观察指标为死亡率。2021年6月完成了由图书馆员协助的对五个数据库（Medline、Embase、Web of Science、CINAHL、Cochrane试验）的检索（2022年11月更新）。分别使用ROBINS-1和ROB-2工具评估观察性研究和随机对照研究中的偏倚风险。采用逆方差法和随机效应模型进行统计分析，数据以风险比及相关95%置信区间的形式报告。通过分析I统计量评估研究的异质性。
纳入了七项研究（六项观察性研究和一项随机试验），共三千零五十名研究参与者纳入分析。四项研究比较了高剂量与低剂量输液，三项研究比较了输液与不输液。我们发现，将标准复苏与限制性复苏进行比较时，死亡率没有差异（风险比0.99，95%置信区间[0.80 - 1.22]，I² = 54%）。
薄弱的、主要为观察性的证据表明，在严重/低血压创伤中，标准液体复苏相对于限制/不进行静脉输液在死亡率方面没有显著益处。本综述补充了证据，对创伤中静脉输液的必要性提出质疑，因为缺乏死亡率获益，此外还表明该领域需要更多的随机研究。
