Permissive Hypotension vs. Conventional Resuscitation Strategies in Adult Trauma Patients with Hemorrhagic Shock: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background Aggressive fluid resuscitation in trauma promotes deleterious effects such as clot disruption, dilutional coagulopathy and hypothermia. Animal studies suggest that permissive hypotension maintains appropriate organ perfusion, reduces bleeding and improves mortality. This review assesses the efficacy and safety of permissive hypotension in adult trauma patients with hemorrhagic shock. Methods We searched the MEDLINE and EMBASE databases from inception to May 2017 for randomized controlled trials comparing permissive hypotension vs. conventional resuscitation following traumatic injury. We included pre-operative and intraoperative resuscitation strategies. The primary outcome was 30-day or in-hospital mortality. Secondary outcomes included blood product utilization, estimated blood loss and in-hospital complications. Pooling was performed with a random-effects model. Results We screened 722 abstracts, from which five randomized trials evaluating 1158 patients were included. Blood pressure targets in the intervention arms varied from systolic BP 50 – 70 mmHg or MAP ≥ 50 mmHg as compared to systolic BP 65 – 100 mmHg or MAP ≥ 65 in the control arms. Two studies evaluated only patients with penetrating injury while the remaining three additionally included blunt injuries. Four trials suggested a survival benefit for 30-day or in-hospital mortality with hypotensive resuscitation, although three studies were insufficiently powered to find statistical significance. Studies were of poor to moderate quality due to poor protocol reporting and lack of blinding. The pooled odds ratio was 0.70 (95% CI 0.53 to 0.92), suggesting a survival benefit for permissive hypotension. Those patients received fewer blood products and had lesser estimated blood loss. Conclusion Permissive hypotension may offer a survival benefit over conventional resuscitation for patients with hemorrhagic injury. It may additionally reduce blood loss and blood product utilization. However, the majority of studies were underpowered, thus reflecting a need for high quality, adequately powered trials. Level of Evidence Systematic Review, Level II PROSPERO Registration CRD42017070526 Corresponding Author: Maher Matar, Division of General Surgery, the Ottawa Hospital, Ottawa, Canada, The Ottawa Hospital - Civic Campus, 1053 Carling Avenue CPC, Suite 330, Ottawa, ON, K1Y 4E9, Email: mmatar@toh.ca There are no funding disclosures or conflicts of interest to declare. This paper was not presented at any meetings. © 2018 Lippincott Williams & Wilkins, Inc.

from Emergency Medicine via xlomafota13 on Inoreader http://ift.tt/2DztNrM