IV Fluids increase death rate for trauma victims

Except the study doesn't go in to detail as to WHY it caused possible harm, the fluid used, if the agency in question had permissive hypotension etc etc



4.8% mortality vs 4.5% is not that big of a difference, even with the big sample body. That's 1,000 more people... in a single study, with many variables that I doubt they took in to account.
 
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I have this conversation with co workers all the time and so many still believe in the 2 large bore IV massive fluid infusion theory fopr trauma victims. With the wars in Iraq and Afghanistan we are learning a lot. 18 gauge is plenty good and limit fluids only enough to keep cerebral perfusion if patient is hypotensive.
 
I'm with Linuss, too many relevant variables not addressed in this study.
 
http://www.ncbi.nlm.nih.gov/pubmed/21178760

That's the actual article in question.....

OBJECTIVE: Prehospital intravenous (IV) fluid administration is common in trauma patients, although little evidence supports this practice. 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.

METHODS: We performed a retrospective cohort study of patients from the National Trauma Data Bank. Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital IV fluid administration, using patient demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on mechanism (blunt/penetrating), hypotension, immediate surgery, severe head injury, and injury severity score.

RESULTS: A total of 776,734 patients were studied. Approximately half (49.3%) received prehospital IV. Overall mortality was 4.6%. Unadjusted mortality was significantly higher in patients receiving prehospital IV fluids (4.8% vs. 4.5%, P < 0.001). Multivariable analysis demonstrated that patients receiving IV fluids were significantly more likely to die (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.17). The association was identified in nearly all subsets of trauma patients. It is especially marked in patients with penetrating mechanism (OR 1.25, 95% CI 1.08-1.45), hypotension (OR 1.44, 95% CI 1.29-1.59), severe head injury (OR 1.34, 95% CI 1.17-1.54), and patients undergoing immediate surgery (OR 1.35, 95% CI 1.22-1.50).

CONCLUSIONS: The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.
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Especially since they, atleast per the artcle (I can't see it in the study) say "The researchers suggest that inserting an IV can mean critical delays in getting to the hospital", yet provide no proof that such delay exists, let alone attributed to the mortality.


I've started IVs en route. Every medic has. I don't know of any (though I know some exists... they always do) medic that stayed on scene just for an IV.
 
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The title almost never says it all.

Titles from the NYT rarely say anything, especially about complicated medical issues, although I am very surprised to see an article about this issue in a newspaper.

I think that interpreting this study is very difficult, something that is probably true for all retrospective studies that rely on complicated statistical analyses of large datasets. There are many variables that may not be appreciated and may have contributed to outcomes here(transport time, setting, true injury severity, IV en route or on scene, air vs. ground, etc. etc.). The authors couldn’t even determine if fluids were given through the IV or if a lock was placed without fluids given (never mind determining how much fluid was given). Side note: Irksome to me is that their less than precise labeling which sometimes implies that they are looking at actual fluid administration.

I think in this case the top of page 6 really says it all. “This retrospective study suffers from some inherent limitations, largely due to potential residual confounders […long list of very important confounders, as mentioned…]. Due to these limitations, we could not determine the potential causal pathway of the higher mortality.”

Sorry, but I don’t really see what this adds to our knowledge. I think this would be great to provide lots of hypotheses to test in prospective studies, as this study does suggest that there may be harm due to IV placement in many groups of patients. However, such hypotheses have already been generated, and in some cases tested, and this study is certainly not sufficient to provide strong evidence for or against the use of IV’s in any cohort. I don’t think we needed the authors to tell us that we need more data about fluid administration in trauma, and I don’t think they gave us any new perspective.

The authors say that they were spurred to analyze the data based on other prospective studies of fluid administration, but the logic of performing a retrospective sort-of-controlled analysis to add credence to a prospective, randomized, controlled trial escapes me a bit. The discussion is interesting but really is just a very stripped down review of the literature.

Side rant 2: I’m also very irked by their repeated use of the term “harm” to describe the interaction between prehospital IV’s and outcome. It is very possible that in many patients here the prehospital IV did cause harm, but the word harm implies a causal relationship between the intervention and the outcome, and this study did NOT establish causality, as they acknowledge.
 
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If you create a "study" in order to prove a point, you are likely to succeed.

Anyone who has ever seen the studies on increased cranial volume correlating to intelligence would know that.

(Which by the way was at one time considered sound, reproducable science.)

The various methodologies were highly questionable. It is sometimes difficult to find people who will go against the prevailing accepted science at a given time. Those who do are often branded as "mad" or "heretical."
 
Without knowing the details of the patients' severity levels and how it was determined who got an IV versus who didn't, I almost wonder if this could be one of those studies that can be summed up as "sicker people die more often". Regardless, like everyone else has said, it doesn't seem from face value to be especially weighty.

Linuss said:
I've started IVs en route. Every medic has. I don't know of any (though I know some exists... they always do) medic that stayed on scene just for an IV.
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I was taught during my internship to get all of my IV's en route, which is probably what I will continue to do for a while, though after having worked with at least one paramedic who got his IV's on scene for non-critical medical patients, that does seem to free up a lot of time en route to do other stuff if you get those before you get going.
 
For non-critical patients, I have no problem with getting the IV on site.

Heck, even if we go en route on say, an MI, and I think it's going to be a tough stick, I can and have asked my partner to pull over for a couple of seconds just so I can get the IV and not risk missing them because of bumps in the road.



However, if they are super critical, we're constantly in motion and if I can't get the IV, they get an IO.
 
Linuss said:
For non-critical patients, I have no problem with getting the IV on site.

Heck, even if we go en route on say, an MI, and I think it's going to be a tough stick, I can and have asked my partner to pull over for a couple of seconds just so I can get the IV and not risk missing them because of bumps in the road.



However, if they are super critical, we're constantly in motion and if I can't get the IV, they get an IO.
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When working the ground unit, I will typically get the patient to the rig after doing a quick assessment and will have my partner get a BP on the right arm while I start an IV on the left and hang a bag of whatever fluid is called for.. If it is a pain management situation like an obvious fracture with deformity, I will of course wait for the patient's vitals, ask them about drug allergies (usually I have already done my SAMPLE history at this point or at least half of it anyways), ask their pain level 1 - 10 (which in that situation is quite obvious), then push the med and then my partner will jump in the front and we will get gone. I rarely ever start an IV outside of the rig, not because there is anything wrong with it, it is just my preference.
 
Agreed, I usually don't do it on scene, just on site (in the ambulance... a lot more control), of course the exception being stuff like hypoglycemia / unresponsive, things of that nature.


Heck, had a "stabbing" the other night, he didn't get an IV till about halfway through the transport.
 
The only times I would ever start an IV on scene is for cardiac arrests, unstable arrhythmias and hypoglycemia (though ironically enough I made it throughout my entire internship without ever giving dextrose).

But we may be getting off topic...

I agree completely that permissive hypotension (systolic around 90) seems to be the magic number when it comes to fluid therapy for trauma patients, and I believe that's the current (or soon to be current?) PHTLS guidelines, so to say that all prehospital IV's on trauma patients are harmful is a little hard to swallow. Even if you're not planning on giving fluid, having that IV for the hospital saves THEM time to delivering definitive care. As for fluid boluses, there are certainly patients who are so messed up that you're turning their blood pink just to try and maintain their pressures, but I would call those lost causes regardless of whether or not we give fluids.

Certainly the key to truly making prehospital trauma care substantially more beneficial and effective in decreasing mortality in trauma patients lies in oxygen carrying blood substitutes.
 
Bieber said:
The only times I would ever start an IV on scene is for cardiac arrests, unstable arrhythmias and hypoglycemia (though ironically enough I made it throughout my entire internship without ever giving dextrose).

But we may be getting off topic...

I agree completely that permissive hypotension (systolic around 90) seems to be the magic number when it comes to fluid therapy for trauma patients, and I believe that's the current (or soon to be current?) PHTLS guidelines, so to say that all prehospital IV's on trauma patients are harmful is a little hard to swallow. Even if you're not planning on giving fluid, having that IV for the hospital saves THEM time to delivering definitive care. As for fluid boluses, there are certainly patients who are so messed up that you're turning their blood pink just to try and maintain their pressures, but I would call those lost causes regardless of whether or not we give fluids.

Certainly the key to truly making prehospital trauma care substantially more beneficial and effective in decreasing mortality in trauma patients lies in oxygen carrying blood substitutes.
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Yes, PHTLS says 90 mmHg last I remember.. which is good for maintaining a MAP where it needs to be.
 
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MAP and CPP really are the key indicators for where our perfusion goals should be. Unfortunately most pre hospital providers are so fixated on systolic and diastolic BP they lose sight of that key piece of data.

Trauma is a difficult beast to study, even more so in the out of hospital setting. I tend to agree with Vene, if you set out to prove a point with a study, you are likely to succeed, until the next group comes along, and depending on who they are funded by, proves you wrong...
 
WTEngel said:
MAP and CPP really are the key indicators for where our perfusion goals should be. Unfortunately most pre hospital providers are so fixated on systolic and diastolic BP they lose sight of that key piece of data.

Trauma is a difficult beast to study, even more so in the out of hospital setting. I tend to agree with Vene, if you set out to prove a point with a study, you are likely to succeed, until the next group comes along, and depending on who they are funded by, proves you wrong...
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[Systolic + 2(diastolic)] / 3 is always one of the first calculations I do when I get a blood pressure on a trauma patient (I like my first blood pressure to always be manual). I like patients who are cathed as well. Urine output is a great indicator of shock, but that discussion is for another thread..

Back on track.
 
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Roger that Rob. It amazes some people that there's more to it than "a top number and a bottom number"
 
The straw that broke the camel's back!

That's pretty much IT!

Essentially, EVERYTHING I used as a paramedic in 1975 has been debunked, deemed ineffective or outright banned due to "poor patient outcome"

Essentially, in those years, I was an agent of Death!

Harsh reality, this site!
 
firetender said:
That's pretty much IT!

Essentially, EVERYTHING I used as a paramedic in 1975 has been debunked, deemed ineffective or outright banned due to "poor patient outcome"

Essentially, in those years, I was an agent of Death!

Harsh reality, this site!
Click to expand...

"Rampart, Squad 51."

"Go ahead, Johnny."

"Rampart, we have a 53 year old medic in shock. Request orders to ship him to Australia, where all smart people head for their no good, very bad days."

"Negative, Squad 51, continue as before, load him up and bring him in."



It does suck to hear though, doesn't it?
 
Interesting study. Very interesting. I would like to see more studies confirm this basis. If they do and it's clear that pre-hospital IV fluids lead to higher mortality rates then I would be in favor or removing that from the protocol, or at least adding permissive hypotension. IV access for medical cases is obvious, however.
 
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