Morrison and coworkers present an interim analysis (90 out of 271 planned patients) of the results of their single-center PRC trial investigating the effects of intraoperative “hypotensive resuscitation” on infusion and transfusion requirements, the incidence of coagulopathy as well as 30-day mortality in traumatized patients suffering from uncontrolled bleeding and hemorrhagic shock. Patients undergoing emergent laparotomy or thoracotomy for blunt or penetrating trauma who had at least one in-hospital documented systolic blood pressure ≤ 90 mmHg were randomized on arrival to the OR to either (1) a low mean arterial pressure group (LMAP n = 44; target minimum MAP 50 mmHg) or (2) a high mean arterial pressure group (HMAP n = 46; target minimum MAP 65 mmHg). Excluded were patients younger than 14 and older than 45 years as well as patients suffering from head and brain injury. No intravenous fluid was administered in the field or during transport to the hospital. About 1 liter of normal saline was administered in both groups preoperatively in the ER.
There were no statistically significant differences with regard to the amount of crystalloid, colloid, total intravenous fluids, or estimated blood loss between the two groups. Transfusion volumes (PRBC, FFP, platelet concentrates) were significantly higher in the HMAP group. Early death (within 24 hours) due to coagulopathy was significantly more frequent in the HMAP group. Of those patients who survived the operation after control of surgical bleeding, significantly fewer deaths occurred in the LMAP group during the first 24 postoperative hours. Overall 30-day mortality was not different between groups. The amount of intraoperative transfusion was identified as an independent risk factor for mortality.
The authors conclude that in the actual state of their investigation intraoperative “hypotensive resuscitation” is a safe procedure in severely traumatized patients that reduces the amount of blood products transfused and reduces the risk of early mortality from coagulopathy.
– Oliver Habler