Crystalloid administration during trauma resuscitation: does less really equal more?

BACKGROUND: Current direction in trauma resuscitation includes emphasis on minimizing crystalloid, along with early transfusion of blood products. Although evidence suggests that higher crystalloid volume during the first 24 hours is associated with negative outcomes, the effect of crystalloid administration during initial resuscitation remains unclear. The purpose of this study was to evaluate the impact of the ratio of crystalloid to packed red blood cells (C/PRBCs) infused during initial emergency department resuscitation on pulmonary morbidity and mortality.

METHODS: Over 6.5 years at a Level 1 trauma center, prospective data were collected on patients that received more than 1 PRBC unit in the resuscitation room. C/PRBC was defined as the ratio of crystalloid infused in liters to the units of PRBCs transfused in the resuscitation room. Patients were stratified by high ratio (>0.75) versus low ratio (<0.75). Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were determined for the association between C/PRBC group and outcomes, namely, adult respiratory distress syndrome (ARDS), 24-hour mortality, and in-hospital mortality.

RESULTS: A total of 383 patients met study criteria: 192 (50%) in the high-ratio and 191 (50%) in the low-ratio group. Variables associated with in-hospital mortality were Injury Severity Score (ISS) (OR, 1.05; 95% CI, 1.03-1.07), admission base excess (OR, 0.94; 95% CI, 0.90-0.98), and time in the resuscitation room (OR, 1.01; 95% CI, 1.00-1.03). Variables associated with 24-hour mortality were ISS (OR, 1.04; 95% CI, 1.02-1.06) and base excess (OR, 0.95; 95% CI, 0.91-1.00). Only ISS (OR, 1.05; 95% CI, 1.02-1.07) was associated with ARDS. ARDS (OR, 1.43; 95% CI, 0.75-2.73), 24-hour mortality (OR, 0.89; 95% CI, 0.49-1.63), and in-hospital mortality (OR, 0.89; 95% CI, 0.52-1.53) were not associated with C/PRBC.

CONCLUSION: In this cohort of patients receiving PRBC in the resuscitation room, factors related primarily to injury severity were associated with pulmonary morbidity and mortality, but C/PRBC was not. Pertaining to initial resuscitation, the purported benefit of crystalloid limitation was not observed.

LEVEL OF EVIDENCE: Therapeutic study, level IV; prognostic study, level III.