Prehospital IV Fluids May Be Harmful for Trauma Victims

Laurie Barclay, MD

January 20, 2011

January 20, 2011 — Prehospital administration of intravenous (IV) fluids may be harmful for trauma victims, and routine use should be discouraged, according to the results of a retrospective cohort study reported in the February issue of the Annals of Surgery.

"Prehospital [IV] fluid administration is common in trauma patients, although little evidence supports this practice," write Elliott R. Haut, MD, from the Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine in Baltimore, Maryland, and colleagues. "We hypothesized that trauma patients who received prehospital IV fluids have higher mortality than trauma patients who did not receive IV fluids in the prehospital setting."

Using multiple logistic regression, the investigators studied mortality as the primary outcome measure among patients from the National Trauma Data Bank who did and who did not receive prehospital IV fluids. Patient demographics, mechanism of trauma (blunt or penetrating), physiologic and anatomic injury severity, and other prehospital procedures were used as covariates. Subgroup analysis was performed based on trauma mechanism, hypotension, immediate surgery, severe head injury, and injury severity score.

Among 776,734 patients studied, 49.3% received prehospital administration of IV fluids. Overall mortality was 4.6%, with unadjusted mortality significantly higher in patients given prehospital IV fluids (4.8% vs 4.5%; P < .001; odds ratio [OR] for death, 1.11; 95% confidence interval [CI], 1.05 - 1.17). Although nearly all subgroups of trauma patients demonstrated this association, it was particularly evident in patients with penetrating trauma (OR, 1.25; 95% CI, 1.08 - 1.45), with hypotension (OR, 1.44; 95% CI, 1.29 - 1.59), with severe head injury (OR, 1.34; 95% CI, 1.17 - 1.54), and undergoing immediate surgery (OR, 1.35; 95% CI, 1.22 - 1.50).

"The harm associated with prehospital IV fluid administration is significant for victims of trauma," the study authors write. "The routine use of prehospital IV fluid administration for all trauma patients should be discouraged."

Limitations of this study include a retrospective design with potential residual confounders, the inability to determine whether excess mortality in patients treated with IV fluids was directly associated with delays in transport to definitive care, and a lack of data to investigate any possible dose-response relationship.

"Proponents of the 'scoop-and-run' philosophy argue for a rapid transfer to definitive care and avoidance of many prehospital procedures," the study authors conclude. "Simultaneously, advocates of the 'stay-and-play' approach suggest that more patients may reach the hospital alive and perhaps have better neurologic outcomes after brain injury with appropriately chosen prehospital interventions. Some important clinical questions (such as those raised by this debate) are not amenable to a randomized clinical trial and therefore must often be answered by other approaches such as observational studies."

This work was presented at the Eastern Association for the Surgery of Trauma Annual Meeting in Orlando, Florida, on January 16, 2009. The study authors have disclosed no relevant financial relationships.

Ann Surg. 2011;253:371-378.

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