10-Year trend in crystalloid resuscitation: Reduced volume and lower mortality

Background: Liberal emergency department (ED) resuscitation after trauma may lead to uncontrolled hemorrhage, reduced organ perfusion, and compartment syndrome. Recent guidelines reduced the standard starting point for crystalloid resuscitation from 2 L to 1 L and emphasized "balanced" resuscitation. The purpose of this study was to characterize how an urban, Level 1 trauma center has responded to changes in crystalloid resuscitation practices over time and to describe associated patient outcomes. Methods: This is a retrospective review of trauma patients who sustained moderate to severe injury (ISS > 9) and received crystalloid resuscitation in the ED during 1/2004-12/2013 at an urban, Level 1 trauma center. Patient data collected included age, gender, Glasgow Coma Scale (GCS) score, initial systolic blood pressure (SBP), mechanism of injury, regional Abbreviated Injury Scale (AIS) score, Injury Severity Score ( ISS), volume of blood products and crystalloids administered in the ED. Patients who received <2 L of crystalloid were considered low-volume while those who received >= 2 L were high-volume patients. Clinical characteristics and outcomes were compared between high- and low-volume cohorts, and multivariate regression was used to adjust for confounders. Trend analysis examined changes in variables over time. Results: 1571 moderate to severely injured patients received crystalloid resuscitation; 1282 (82%) were low-volume and 289 (18%) were high-volume. Compared to high-volume patients, low-volume patients presented with a higher median SBP (134 vs. 122 mmHg, p < 0.001) and GCS (15 vs. 14, p < 0.001). Low-volume patients also had lower median ISS (15 vs. 19, p < 0.001). Unadjusted mortality was lower in the low-volume cohort (7% vs. 19%, p < 0.001). Multivariate analysis demonstrated that high-volume patients had increased odds of mortality compared to low-volume patients (AOR 1.88, p - 0.008). Decreased rates of high-volume resuscitation and overall mortality were demonstrated over the 10-year study period. Conclusions: The observed decrease in high-volume crystalloid resuscitations in the ED paralleled a reduction in mortality over the ten-year period. In addition, adjusted mortality was higher in those receiving high-volume resuscitation. (C) 2016 IJS Publishing Group Ltd.