Prehospital hypertonic fluid resuscitation for trauma patients: A systematic review and meta-analysis

de Crescenzo, Claire MD; Gorouhi, Farzam MD; Salcedo, Edgardo S. MD; Galante, Joseph M. MD

Journal of Trauma and Acute Care Surgery: May 2017 - Volume 82 - Issue 5 - p 956–962
doi: 10.1097/TA.0000000000001409
Systematic Review

BACKGROUND: Prehospital assessment of a patient’s circulation status and appropriate resuscitation with intravenous fluids plays a critical role in patients with obvious hemorrhage or systolic blood pressure below 90 mm Hg.

OBJECTIVES: We assessed the efficacy and safety of prehospital administration of crystalloids or colloids to improve the survival rate of trauma patients with acceptable safety profile.

DATA SOURCES: We searched SCOPUS, Embase, TRIP database, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and PubMed as per search protocol from January 1, 1900 to February 12, 2015.

STUDY ELIGIBILITY CRITERIA: All randomized controlled trials were considered.

PARTICIPANTS AND INTERVENTIONS: All patients had penetrating or blunt trauma, excluding traumatic brain or thermal injuries. At least one of the comparators should be a crystalloid or colloid.

STUDY APPRAISAL AND SYNTHESIS METHODS: Detailed search strategy was developed and utilized. Duplicates were removed from the search results. We, the co-first authors (C.d.C. and F.G.), independently reviewed the article titles and abstracts to assess eligibility. Eligible articles were downloaded for full text review to determine inclusion in the review and analysis. We (C.d.C. and F.G.) performed a methodological quality assessment of each included article. The primary outcome was mortality. The secondary outcomes included adverse events, infections, multiple organ dysfunction score, and length of stay at the hospital. Heterogeneity was measured by I2 value. An I2 value greater than 50% was considered to be substantial heterogeneity. Fixed effect analysis and random effect analysis were performed when needed.

RESULTS: A total of nine trials (3,490 patients) were included in the systematic review, and six trials were included in meta-analyses. There were no significant differences between hypertonic saline with dextran and lactated Ringer’s solution in 1 day using two studies (2.91; 95% CI, 0.58–14.54; p = 0.19) and 28- to 30-day survival rates using another two studies (1.47; 95% CI, 0.30–7.18; p = 0.63). Adding dextran to hypertonic saline did not increase the survival rate (0.94; 95% CI, 0.65–1.34; p = 0.71). Overall, complications were comparable between all groups.

LIMITATIONS: The quality of some of the included studies is not optimal.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: There is no beneficial effect of hypertonic saline with or without dextran in general traumatic patients. Further trials to evaluate its benefit in patients with penetrating trauma requiring surgery are warranted.

LEVEL OF EVIDENCE: Systematic review and meta-analysis, level I.

From the Division of Trauma, Acute Care Surgery, and Surgical Critical Care (C.D.C., F.G., E.S.S., J.M.G.), University of California Davis School of Medicine, Sacramento, California.

Submitted: July 4, 2016, Revised: January 1, 2017, Accepted: January 18, 2017, Published online: March 2, 2017.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.jtrauma.com). *C.d.C. and F.G. contributed equally to this study.

Address for reprints: Joseph M. Galante, MD, Division of Trauma and Acute Care Surgery, University of California Davis School of Medicine; email: jmgalante@ucdavis.edu.

© 2017 Lippincott Williams & Wilkins, Inc.