Permissive Hypotension Research Articles

Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Protocol for the 65 randomised clinical trial

Vasodilatory shock is common in critically ill patients and vasopressors are a mainstay of therapy. A meta-analysis suggested that use of a higher, as opposed to a lower, mean arterial pressure target to guide titration of vasopressor therapy, could be associated with a higher risk of death in older critically ill patients. The 65 trial is a pragmatic, multi-centre, parallel-group, open-label, randomised clinical trial of permissive hypotension (a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial is conducted in 2600 patients from 65 United Kingdom adult, general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. The 65 trial received favourable ethical opinion from the South Central – Oxford C Research Ethics Committee and approval from the Health Research Authority. The results will be presented at national and international conferences and published in peer-reviewed medical journals. Trial registration: ISRCTN10580502

Evaluating the clinical and cost-effectiveness of permissive hypotension in critically ill patients aged 65 years or over with vasodilatory hypotension: Statistical and Health Economic Analysis Plan for the 65 trial

The 65 trial is a pragmatic, multicentre, parallel-group, open-label, randomised clinical trial of permissive hypotension (targeting a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial will recruit 2600 patients from 65 United Kingdom adult general critical care units. The primary outcome is all-cause mortality at 90 days. An economic evaluation is embedded. This paper describes the proposed statistical and health economic analysis for the 65 trial.

Robust IMC-PID and Parameter-varying Control Strategies for Automated Blood Pressure Regulation

The present work focuses on comparing a robust and a parameter-varying control design approach for automatically regulating blood pressure in critical hypotensive patients using vasopressor drug infusion. Mean arterial pressure (MAP) response of a patient subject to vasoactive drugs is modeled by a first-order dynamical system with time-varying parameters and a time-varying delay in the control input which limits the implementation of conventional control techniques. Two methods are examined to address the variability and the time-varying delay of the physiological response to the drug. First, a Pade approximation is used to transform the infinite-dimensional delay problem into a finite-dimensional model represented in the form of a non-minimum phase (NMP) system. A systematic parameter-varying loop-shaping control is proposed to provide the closed-loop system with stability and tracking performance in the presence of measurement noise and disturbances. Second, an internal model control (IMC) strategy is examined to design a fixed proportional-integral-derivative (PID) controller cascaded with a lag compensator by considering the time-varying model to be a perturbed uncertain system. To account for system uncertainty, the small-gain theorem is employed by which robust stability conditions are investigated. The proposed control methods are applied to critical hypotensive patient resuscitation to regulate MAP while considering the limitations posed by the time-varying parameters of the physiological response model and the large time-varying delay. Simulation results are provided and compared to evaluate the performance of the proposed control actions under various hypotensive scenarios.

Damage control resuscitation in children

Damage control resuscitation is a relatively new resuscitative strategy for patients with severe traumatic hemorrhage. This strategy consists of permissive hypotension and early balanced transfusion, and transfers the patients to subsequent surgery. There is growing evidence on harms of excessive fluids. Since 2013, survival benefit of massive transfusion protocol has been proven in adults. Despite insufficient evidence, pediatric massive transfusion protocols are widely used in North American trauma centers. This review focuses on the concept of damage control resuscitation, and summarizes the relevant pediatric evidence. Key Words: Blood Coagulation Disorders; Blood Transfusion; Child; Emergency Medicine; Hemostasis; Hypotension, Controlled; Resuscitation; Wounds and Injuries

Recombinant Factor XIIIA and ACTH(1‐24) as Adjuncts During Prolonged Hypotensive Resuscitation in swine (Sus scrofa domesticus): Optimizing Outcomes for the Prolonged Field Care Environment

BackgroundTraumatic injuries with hemorrhage are the leading cause of potentially survivable death in trauma. A permissive hypotension strategy (Goal resuscitation systolic blood pressure (SBP) of 80–90 mmHg) plus early blood product administration over a short transport interval has been linked to improved survival. If blood products are unavailable during this pre‐hospital time, crystalloids and colloids such as hydroxy ethyl starch (Hextend®) remain the standard fielded resuscitative fluid. However, studies have demonstrated the correlation of kidney injury and failure, increased risk of coagulopathy, and higher mortality risk with this treatment. To improve outcomes in this prolonged field care (PFC) setting, in the absence of blood products, we investigated the survival and therapeutic benefits of ACTH(1‐24) and rFXIIIA treatment as an adjunct to Hextend® in a permissively hypotensive PFC model of hemorrhagic shock in swine.MethodsAnesthetized male swine (n = 16) underwent pressure‐targeted, decompensated hemorrhagic shock (MAP = 30–35 mmHg) for 45 minutes followed by permissively hypotensive (SBP = 80–90) resuscitation with Hextend® for 8 hours (with or without adjuncts such as ACTH(1‐24)), simulating a PFC environment. At the end of PFC, animals were fully resuscitated (return of shed blood plus normal saline). Animals were then monitored for 24 hours and assessed for neurocognitive function via latency to food reward. Sham animals (n = 5) received only anesthesia for the same time period. Tissues and serum were isolated at euthanasia for histopathological and biomarker analysis. Results reported as mean ± SD, Statistics: two‐way ANOVA with P < 0.05 significance.ResultsInitial results from this experiment indicate successful use of 500 mL (n = 5) versus 1L (n = 5) of Hextend® to model a survivable permissively hypotensive state (SBP 80–90) for up to 8 hours in swine. Hextend® treatment amount shows no significant deleterious cardiovascular (HR, BP; p > 0.05) or metabolic effects (lactate, BD; p > 0.05) following initial shock treatment. ROTEM analysis indicated ACTH treatment (n = 1) decreased the latency for clot formation time in the later stages of PFC compared to the Hextend® + vehicle control. Additionally, there were no significant neurological detriments induced by the prolonged permissive hypotensive state, which makes this model ideal for PFC studies of shock (p > 0.05).ConclusionThis swine model of prolonged permissively hypotensive resuscitation was designed to align with pre‐hospital hemorrhage control. The use of ACTH as an adjunct to standard treatments may improve outcomes, specifically with regard to bleeding. These results extend beyond military application to the rural civilian environment, where extended pre‐hospital times are commonplace. Further investigation is underway to elucidate whether rFXIIIA + ACTH, as a combination treatment, could improve PFC outcomes.Support or Funding InformationThis work was supported by the Defense Medical Research and Development Program, Joint Program Committee 6/Combat Casualty Care Research Program.This abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Thoracic trauma in military settings: a review of current practices and recommendations.

To examine current literature on thoracic trauma related to military combat and to explore its relevance to the civilian population. Damage control resuscitation (DCR) has improved the management of hemorrhaging trauma patients. Permissive hypotension below 110 mmHg and antifibrinolytic use during DCR is widely accepted, whereas the use of freeze-dried plasma and whole blood is gaining popularity. The Modified Physiologic Triaging Tool can be used for primary triage and it may have applications in civilian trauma systems. Although Tactical Combat Casualty Care protocol recommends the Cric-Key device for surgical cricothyroidotomies, other devices may offer comparable performance. Recommendations for regional anesthesia after blunt trauma are not well defined. Increasing amounts of evidence favor the use of extracorporeal membrane oxygenation for refractory hypoxemia and resuscitative endovascular balloon occlusion of the aorta (REBOA) for severe hemorrhage. REBOA outcomes are potentially improved by partial occlusion and small 7 Fr catheters. The Global War on Terror has provided opportunities to better understand and treat thoracic trauma in military settings. Trauma registries and other data sources have contributed to significant advancements in the management of thoracic trauma in military and civilian populations.

Five years of prolonged field care: prehospital challenges during recent French military operations.

French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.

Indices of Organ Damage after Surviving Hemorrhage and Prolonged Hypotension

BACKGROUNDHypotensive resuscitation to raise systolic pressure to 80–90 mm Hg is the standard of care on the battlefield for hemorrhaging Soldiers, and is maintained until the casualty is transported to a surgical unit usually within one hour of injury. Prompt evacuations may not be possible in future conflicts, and hypotension will be required for longer periods of time. This study determined the long‐term effects of prolonged hypotension (PH) held for 0, 1, 2 and 3 hours on kidney, liver and muscle damage up to 21 days after PH, and tested the hypothesis that longer duration of hypotension after hemorrhage will result in greater organ damage.METHODSMale baboons were anesthetized and hemorrhaged until systolic blood pressure was 70 mmHg for 10 min. Systolic blood pressure of greater than 80 mm Hg with autologous blood was maintained for 1 hour (1hr PH; n=5), 2 hours (2hr PH; n=5), or 3 hours (3hr PH; n=5) hours. After the PH period, the hemorrhage volume of whole blood was replaced, and the animal was recovered and monitored for 21 days. Control animals were anesthetized, hemorrhaged and immediately resuscitated with hemorrhaged blood (0hr PH, n=3). Blood samples were obtained before and 1, 3, 7, 14 and 21 days after PH, and analyzed for blood chemistry profile. Data were analyzed with 2 way repeated measures ANOVA and Holm‐Sidak test, and expressed as Mean ± Standard Deviation.RESULTSPlasma creatinine and blood urea nitrogen were unaffected by PH and remained within normal limits in all PH groups. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatine phosphokinase (CPK), and lactate dehydrogenase (LDH) values were significantly elevated after PH (time effect; P<0.001; PH group effect; P=0.3). Maximum ALT levels were observed on Day 1 after PH in 0hr PH (140 ± 56 U/L), 1hr PH (170 ± 130 U/L), 2hr PH (322 ± 241 U/L), and 3hr PH (387 ± 167 U/L). Maximum AST levels were observed on Day 1 after PH in 0hr PH (218 ± 44 U/L), 1hr PH (354 ± 219 U/L), 2hr PH (515 ± 424 U/L), and 3hr PH (711 ± 278U/L). Maximum CPK values were observed on Day 1 after PH in 0hr PH (7834 ± 3681 U/L), 1hr PH (24336 ± 22268 U/L), 2hr PH (50494 ± 67653 U/L), and 3hr PH (59857 ± 32408 U/L). Maximum LDH values were observed on Day 1 after PH in 0hr PH (890 ± 396 U/L), 1hr PH (2055 ± 1520 U/L), 2hr PH (3992 ± 4895 U/L), and 3hr PH (4771 ± 1884 U/L). Max levels of ALT, AST, CPK, and LDH were positively correlated with the duration of PH (P<0.05). All values returned to pre‐PH levels by 21 days after PH.CONCLUSIONSThese results indicate that PH up to 3 hours in duration results in transient liver and muscle damage that is correlated with the duration of PH in male baboons. PH of any duration produced minimal effects on the kidney. More studies are needed to determine if longer periods of PH result in permanent and more extensive organ damage.Support or Funding InformationThis study was funded by the United States Army, Medical Research and Materiel CommandThis abstract is from the Experimental Biology 2019 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Permissive Hypotension for Trauma Patients with Hemorrhagic Shock

In 1994, a large trial (N Engl J Med 1994; 331:17) demonstrated decreased mortality with delayed crystalloid resuscitation in hypotensive patients with

Acute traumatic coagulopathy: the lethal triad of trauma

Trauma is the leading cause of death for people in the UK and North America, especially for those aged 15–24 years. However, if early management regimes of permissive hypotension, high-flow oxygen and administration of tranexamic acid are applied, mortality risk can be reduced significantly. Acute traumatic coagulopathy (ATC) is an internal process that is initiated by significant or massive trauma because of hypoperfusion resulting in hypovolaemic shock, activation of protein C, platelet dysfunction and disruption to the endothelial glycocalyx. ATC can be exacerbated by hypothermia, acidosis and dilution coagulopathy—the ‘lethal triad’ of trauma. This article discusses the pathophysiology of ATC and treatment strategies via the management of the lethal triad.

Risks and benefits of hypotensive resuscitation in patients with traumatic hemorrhagic shock: a meta-analysis

BackgroundDamage control strategies play an important role in trauma patient management. One such strategy, hypotensive resuscitation, is being increasingly employed. Although several randomized controlled trials have reported its benefits, the mortality benefit of hypotensive resuscitation has not yet been systematically reviewed.ObjectivesTo conduct a meta-analysis of the efficacy of hypotensive resuscitation in traumatic hemorrhagic shock patients relative to mortality as the primary outcome, with acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and multiple organ dysfunction as the secondary outcomes.MethodsPubMed, Medline-Ovid, Scopus, Science Direct, EMBASE, and CNKI database searches were conducted. An additional search of relevant primary literature and review articles was also performed. Randomized controlled trials and cohort studies reporting the mortality rate associated with hypotensive resuscitation or limited fluid resuscitation were selected. The random-effects model was used to estimate mortality and onset of other complications.ResultsOf 2114 studies, 30 were selected for this meta-analysis. A statistically significant decrease in mortality was observed in the hypotensive resuscitation group (risk ratio [RR]: 0.50; 95% confidence interval [CI]: 0.40–0.61). Heterogeneity was observed in the included literature (I2: 27%; degrees of freedom: 23; p = 0.11). Less usage of packed red cell transfusions and fluid resuscitations was also demonstrated. No significant difference between groups was observed for AKI; however, a protective effect was observed relative to both multiple organ dysfunction and ARDS.ConclusionsThis meta-analysis revealed significant benefits of hypotensive resuscitation relative to mortality in traumatic hemorrhagic shock patients. It not only reduced the need for blood transfusions and the incidences of ARDS and multiple organ dysfunction, but it caused a non-significant AKI incidence.

Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers

Introduction: Following life-threatening junctional trauma, the goal is to limit blood loss while expediting transfer to operative rescue. Unfortunately, life-threatening abdominal-pelvic or junctional hemorrhage is often not amenable to direct compression and few temporizing strategies are available beyond hemostatic dressings, hypotensive resuscitation, and balanced transfusion. Objectives: In this study, we evaluated proximal external aortic compression to arrest blood flow in healthy adult men. Methods: This was a simulation trial of proximal external aortic compression, for life-threatening abdominal-pelvic and junctional hemorrhage, in a convenience sample of healthy adult male volunteers. The primary end points were cessation of femoral blood flow as assessed by pulse wave Doppler ultrasound at the right femoral artery, caudal to the inguinal ligament. Secondary end points were discomfort and negative sequelae. Results: Aortic blood flow was arrested in 12 volunteers. Median time to blood flow cessation was 12.5 seconds. Median reported discomfort was 5 out of 10. No complications or negative sequelae were reported. Conclusion: This trial suggests that it may be reasonable to attempt temporization of major abdominal-pelvic and junctional hemorrhage using bimanual proximal external aortic compression. In the absence of immediate alternatives for this dangerous and vexing injury pattern, there appear to be few downsides to prehospital proximal external aortic compression while concomitantly expediting definite care.

Restricted fluid resuscitation in suspected sepsis associated hypotension (REFRESH): a pilot randomised controlled trial.

To determine if a regimen of restricted fluids and early vasopressor compared to usual care is feasible for initial resuscitation of hypotension due to suspected sepsis. A prospective, randomised, open-label, clinical trial of a restricted fluid resuscitation regimen in the first 6h among patients in the emergency department (ED) with suspected sepsis and a systolic blood pressure under 100mmHg, after minimum 1000ml of IV fluid. Primary outcome was total fluid administered within 6h post randomisation. There were 99 participants (50 restricted volume and 49 usual care) in the intention-to-treat analysis. Median volume from presentation to 6h in the restricted volume group was 2387ml [first to third quartile (Q1-Q3) 1750-2750ml]; 30ml/kg (Q1-Q3 32-39ml/kg) vs. 3000ml (Q1-Q3 2250-3900ml); 43ml/kg (Q1-Q3 35-50ml/kg) in the usual care group (p < 0.001). Median duration of vasopressor support was 21h (Q1-Q3 9-42h) vs. 33h (Q1-Q3 15-50h), (p = 0.13) in the restricted volume and usual care groups, respectively. At 90-days, 4 of 48 (8%) in the restricted volume group and 3 of 47 (6%) in the usual care group had died. Protocol deviations occurred in 6/50 (12%) in restricted group and 11/49 (22%) in the usual care group, and serious adverse events in fourcases (8%) in each group. A regimen of restricted fluids and early vasopressor in ED patients with suspected sepsis and hypotension appears feasible. Illness severity was moderate and mortality rates low. A future trial is necessary with recruitment of high-risk patients to determine effects on clinical outcomes in this setting.

Ruptured Abdominal Aortic Aneurysm

Aneurysm rupture is a potentially lethal complication. Open and endovascular treatment show similar mortality rates in high volume centres (15 - 20%). Individual patient management is more important than the choice between open or endovascular repair. Permissive hypotension with fluid restriction and aneurysm morphology suitable for endovascular treatment have a positive impact on mortality after either method of repair. Coronary artery disease, chronic renal impairment, and hypovolaemic shock raise mortality. Reintervention rates after endovascular repair are high and mandate lifelong follow-up.

Damage Control Resuscitation.

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

Transfusion Therapy

Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking. Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

Transfusion Therapy

Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking. Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

Optimizing transfusion strategies in damage control resuscitation: current insights.

From clinical and laboratory studies of specific coagulation defects induced by injury, damage control resuscitation (DCR) emerged as the most effective management strategy for hemorrhagic shock. DCR of the trauma patient who has sustained massive blood loss consists of 1) hemorrhage control; 2) permissive hypotension; and 3) the prevention and correction of trauma-induced coagulopathies, referred to collectively here as acute coagulopathy of trauma (ACOT). Trauma patients with ACOT have higher transfusion requirements, may eventually require massive transfusion, and are at higher risk of exsanguinating. Distinct impairments in the hemostatic system associated with trauma include acquired quantitative and qualitative platelet defects, hypocoagulable and hypercoagulable states, and dysregulation of the fibrinolytic system giving rise to hyperfibrinolysis or a phenomenon referred to as fibrinolytic shutdown. Furthermore, ACOT is a component of a systemic host defense dysregulation syndrome that bears several phenotypic features comparable with other acute systemic physiological insults such as sepsis, myocardial infarction, and postcardiac arrest syndrome. Progress in the science of resuscitation has been continuing at an accelerated rate, and clinicians who manage catastrophic blood loss may be incompletely informed of important advances that pertain to DCR. Therefore, we review recent findings that further characterize the pathophysiology of ACOT and describe the application of this new information to optimization of resuscitation strategies for the patient in hemorrhagic shock.

Permissive Hypotension: What’s New in Fluid Resuscitation in the Management of Hemorrhagic Shock?

Permissive Hypotension: What’s New in Fluid Resuscitation in the Management of Hemorrhagic Shock?

Resuscitative Strategies in the Trauma Patient: The Past, the Present, and the Future.

Over the last decade, trends in fluid resuscitation have changed dramatically as have our practices. Research is driving trauma centers across the globe to initiate modifications in fluid resuscitation of the hemorrhagic trauma patients both in the prehospital and intrahospital arena. This is being done by combining the theory of permissive hypotension and damage control surgery with hemostatic resuscitation as the preferred methods of resuscitation in patients with hemorrhagic shock. The literature illustrates that previous strategies we considered to be beneficial are actually detrimental to the outcomes of these severely injured patients. This complex and continuously changing adaptation in practice must be made without losing our strategic focus of improvement of outcomes and recognition of the morbidity associated with bleeding of the trauma patient. Designating limits on large-volume crystalloid resuscitation will prevent cellular injury. These wiser resuscitation strategies are key in the efforts to reduce mortality and to improve outcomes. This article is to serve as a review of each of the resuscitative fluid strategies as well as new methods of trauma resuscitation.