Abstract
BackgroundWhen resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients. However, evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. This study aimed to assess the impact of vasopressor use in patients with blunt trauma in severe hemorrhagic shock.MethodsIn this single-center retrospective study, we reviewed records of blunt trauma patients with hemorrhagic shock and included patients with a probability of survival < 0.6. Vital signs on arrival, characteristics, examinations, concomitant injuries and severity, vasopressor use and dose, and volumes of crystalloids and blood infused were compared between survivors and non-survivors. Data are described as median (25–75% interquartile range) or number.ResultsForty patients admitted from April 2014 to September 2019 were included. Median Injury Severity Score in survivors vs non-survivors was 41 (36–48) vs 45 (34–51) (p = 0.48), with no significant difference in probability of survival between the two groups (0.22 [0.12–0.48] vs 0.21 [0.08–0.46]; p = 0.93). Despite no significant difference in patient characteristics and injury severity, non-survivors were administered vasopressors significantly earlier after admission and at significantly higher doses. Total blood transfusion amount administered within 24 h after admission was significantly higher in survivors (8430 [5680–9320] vs 6540 [4550–7880] mL; p = 0.03). Max catecholamine index was significantly higher in non-survivors (2 [0–4] vs 14 [10–18]; p = 0.008), and administered vasopressors were terminated significantly earlier (12 [4–26] vs 34 [10–74] hours; p = 0.026) in survivors.Although the variables of severity of the patients had no significant differences, vasopressor use (Odds ratio [OR] = 21.32, 95% confident interval [CI]: 3.71–121.6; p = 0.0001) and its early administration (OR = 10.56, 95%CI: 1.90–58.5; p = 0.005) indicated significant higher risk of death in this study.ConclusionVasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality. Although the transfused volume of blood products tends to be increased when resuscitating these patients, early termination of vasopressor had better to be considered.
Highlights
When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients
Vasopressor administration and high-dose use for resuscitation of hemorrhagic shock following severe blunt trauma are potentially associated with increased mortality
Many reports do not recommend the use of vasopressors for the resuscitation of trauma patients [12, 13], some reports and guidelines have committed to the temporary use of vasopressors for life-threatening hemorrhagic shock to minimize fluid volume administered and maintain appropriate systemic perfusion [14, 15]
Summary
When resuscitating patients with hemorrhagic shock following trauma, fluid volume restriction and permissive hypotension prior to bleeding control are emphasized along with the good outcome especially for penetrating trauma patients Evidence that these concepts apply well to the management of blunt trauma is lacking, and their use in blunt trauma remains controversial. There is still no evidence of these concepts being successfully applied to the management of patients following blunt injury or those with traumatic brain injury (TBI) [7,8,9] Despite these controversies, vasopressors are still globally administered in some trauma patients in severe shock to maintain minimal perfusion pressure especially for the brain or are sometimes used as fluid-sparing adjuncts to resuscitation without diluting clotting factors [10, 11]. Even in level 1 trauma centers, where any surgical or interventional radiographic procedures for the immediate control of bleeding and early activation of massive transfusion protocol (MTP) are always available, the effects and risks of vasopressor administration for severe hemorrhagic shock following trauma remain unclear [16,17,18,19]
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