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Timing and volume of fluid administration for patients with bleeding

  • Review
  • Intervention

Authors

  • Irene Kwan,

    Corresponding author
    1. Royal College of Obstetricians & Gynaecologists, National Collaborating Centre For Women's and Children's Health, London, UK
    • Irene Kwan, National Collaborating Centre For Women's and Children's Health, Royal College of Obstetricians & Gynaecologists, 2-16 Goodge Street, London, W1T2QA, UK. ikwan@ncc-wch.org.uk..

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  • Frances Bunn,

    1. University of Hertfordshire, Centre for Research in Primary and Community Care, Hatfield, Hertfordshire, UK
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  • Ian Roberts

    1. London School of Hygiene & Tropical Medicine, Cochrane Injuries Group, London, UK
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Abstract

Background

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.

Objectives

To assess the effects of early versus delayed, and larger versus smaller volume of fluid administration in trauma patients with bleeding.

Search methods

We searched the CENTRAL (The Cochrane Library 2008, Issue 4), the Cochrane Injuries Group's Specialised Register (searched October 2008), MEDLINE (to October 2008), EMBASE (to October 2008), the National Research Register (in Current controlled trials.gov; searched October 2008) and the Science Citation Index (to October 2008). We checked reference lists of identified articles and contacted authors and experts in the field.

Selection criteria

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.

Data collection and analysis

Two authors independently extracted data and assessed trial quality.

Main results

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=110) RR for death with a high systolic blood pressure resuscitation target (100mmHg) maintained with a larger volume of fluid, as compared to low systolic blood pressure resuscitation target (70mmHg) maintained with a smaller volume of fluid was 1.00 (95% CI 0.26−3.81). In the third trial (n=25) there were no deaths.

Authors' conclusions

We found no evidence from randomised controlled trials for or against 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.

摘要

背景

出血病患的輸液時間與劑量

出血性休克的治療包括維持血壓與組織灌流直到控制出血。不同的限制策略已被用來維持創傷病患的血壓直到控制出血。然而,維持血壓也許可以預防休克,但它也許會惡化出血的情況。

目標

評估早期對照延後,及大量對照少量輸液對於出血的創傷病患的效果。

搜尋策略

我們檢索the Cochrane Controlled Trials Register,the specialised register of the Injuries Group,MEDLINE,EMBASE,the National Research Register及the Science Citation Index。我們檢視已確定文章的參考文獻並連絡該領域的作者與專家。

選擇標準

出血的創傷病患其靜脈輸液之時間與劑量的隨機試驗。排除比較不同類型靜脈輸液的試驗。

資料收集與分析

兩名回顧者分別摘錄資料並評估試驗品質。

主要結論

因為介入措施與病患族群大不相同,因此我們沒有量化地整合結果。早期對照延後輸液:三篇試驗報告死亡率,而兩篇報告凝血的資料。 第一篇試驗(n = 598),早期輸液病患其死亡的相對風險(relative risk (RR)為1.26(95% confidence interval為1.00-1.58)。前凝血酵素與部分凝血活?時間的加權平均差(weighted mean differences (WMD))分別為2.7秒(95% CI為0.9 – 4.5)及4.3秒(95% CI為1.74-6.9)。 第二篇試驗(n = 50),早期輸血病患其死亡的RR為5.4 (95% CI為0.3-107.1)。部分凝血活?時間的WMD為7.0秒(95% CI為6.0-8.0)。 第三篇試驗(n = 1309),早期輸液病患其死亡的RR為1.06 (95% CI為0.77-1.47)。 大量對照少量輸液:三篇試驗報告死亡率,而一篇報告凝血的資料。 第一篇試驗(n = 36),大量輸液病患其死亡的RR為(95% CI為0.28-22.29)。接受大量輸液的病患其前凝血酵素時間與部分凝血活?時間為14.8與47.3秒,比較組則為13.9與35.1秒。 第二篇試驗(n = 110),以大量液體維持高收縮壓限制目標(100mmHg)的病患相較於低收縮壓限制目標的病患其死亡的RR為1.00 (95% CI 0.26-3.81)。 第三篇試驗(n = 25)沒有發現病患死亡。

作者結論

我們沒有發現來自隨機對照試驗的證據以支持或反對早期或大量靜脈輸液用於不受控制之出血狀況。目前仍不清楚關於出血的創傷病患的最佳輸液策略。需要進一步的隨機對照試驗以建立最有效的液體限制策略。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

沒有從試驗獲得證據以支持或不支持對於不受控制的出血使用早期或大量的靜脈液體。大約有1/3的受傷死亡人數是因為休克失血造成的。因此,預防休克病患其不受控制出血是很重要的且通常給予其靜脈液體。目的為維持血壓並減少組織傷害。試驗的回顧發現目前不確定關於給予液體的最佳時機與應該給予多少的液體劑量。增加液體可能會維持血壓,但也可能會因為稀釋血液中的凝血因子而惡化出血情況。需要更多的研究。

Plain language summary

No evidence from trials to support or not to support the use of early or larger volume intravenous fluid in uncontrolled bleeding

About one third of injury deaths are due to shock from blood loss. Preventing shock in people with uncontrolled bleeding is, therefore, very important and is generally done by giving fluids intravenously. The aim is to maintain blood pressure and reduce tissue damage. The review of trials found that there is uncertainty about the best time to give fluid and what volume of fluid should be given. While increasing fluids will maintain blood pressure, it may also worsen bleeding by diluting clotting factors in the blood. More research is needed.

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