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Liberal Versus Restricted Fluid Resuscitation Strategies in Trauma Patients

A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies*

Wang, Chih-Hung MD1; Hsieh, Wen-Han MS2; Chou, Hao-Chang MD1; Huang, Yu-Sheng MD1; Shen, Jen-Hsiang MS3; Yeo, Yee Hui MS4; Chang, Huai-En MS5; Chen, Shyr-Chyr MD, MBA1; Lee, Chien-Chang MD, MSc6,7

doi: 10.1097/CCM.0000000000000050
Review Articles

Objective: Hemorrhage is responsible for most deaths that occur during the first few hours after trauma. Animal models of trauma have shown that restricting fluid administration can reduce the risk of death; however, studies in patients are difficult to conduct due to logistical and ethical problems. To maximize the value of the existing evidence, we performed a meta-analysis to compare liberal versus restricted fluid resuscitation strategies in trauma patients.

Data Sources: Medline and Embase were systemically searched from inception to February 2013.

Study Selection: We selected randomized controlled trials and observational studies that compared different fluid administration strategies in trauma patients. There were no restrictions for language, population, or publication year.

Data Extraction: Four randomized controlled trials and seven observational studies were identified from 1,106 references. One of the randomized controlled trials suffered from a high protocol violation rate and was excluded from the final analysis.

Data Synthesis: The quantitative synthesis indicated that liberal fluid resuscitation strategies might be associated with higher mortality than restricted fluid strategies, both in randomized controlled trials (risk ratio, 1.25; 95% CI, 1.01–1.55; three trials; I2, 0) and observational studies (odds ratio, 1.14; 95% CI, 1.01–1.28; seven studies; I2, 21.4%). When only adjusted odds ratios were pooled for observational studies, odds for mortality with liberal fluid resuscitation strategies increased (odds ratio, 1.19; 95% CI, 1.02–1.38; six studies; I2, 26.3%).

Conclusions: Current evidence indicates that initial liberal fluid resuscitation strategies may be associated with higher mortality in injured patients. However, available studies are subject to a high risk of selection bias and clinical heterogeneity. This result should be interpreted with great caution.

1Department of Emergency Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.

2Department of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.

3Department of Medicine, College of Medicine, Chang-Gung University, Tao-Yuan, Taiwan.

4Department of Medicine, National Defense Medical Center, Taipei, Taiwan.

5Department of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.

6Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan.

7Department of Epidemiology, Harvard School of Public Health, Boston, MA.

* See also p. 1005.

Dr. Lee had full access to all data and has final responsibility to submit the results for publication.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

The authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Chien-Chang Lee, MD, MSc, Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, #.579, Sec. 2, Yunlin Road, Douliou 640, Yunlin, Taiwan. E-mail:

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