LO92: The effect of prehospital intravenous fluids on mortality in trauma: a systematic review and meta-analysis

Abstract

Introduction: Hemorrhage is the primary cause of death in 39% of trauma patients. In prehospital trauma management, there is debate over pursuing a ‘scoop-and-run’ approach versus early intravenous (IV) fluid therapy. We evaluated the literature regarding the effect of prehospital IV fluid therapy on mortality in adult trauma patients. Methods: A librarian-assisted search was conducted in PubMed, Medline and Embase. The population was adults with blunt and/or penetrating trauma. The intervention was total prehospital IV fluid volume 0-500 mL, and the control was prehospital fluid volume >500 mL. The outcome of interest was in-hospital mortality. Randomized controlled trials (RCTs), cohort and case-matched studies were included. Two reviewers used the Cochrane Risk of Bias (RoB) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tools to evaluate biases, and kappa was calculated for inter-rater agreement. A summary relative risk (RR) of in-hospital mortality was calculated and heterogeneity (I2) analysis performed using RevMan 5 software. Results: Four RCT's and eleven observational studies were identified, with n = 15,448 patients. Two RCTs and four observational studies were excluded due to non-English language, and the location or volume of IV fluid administered, leaving eight studies with n = 4,568 patients. Inter-rater agreement was high with the ROBINS-I (unweighted κ=0.8841) and RoB tool (unweighted κ=0.8276). Two studies found decreased mortality, one found increased mortality, and five found no significant relationship to mortality with 0-500 mL prehospital IV fluid. The summary relative risk of mortality with 0-500 mL IV fluid compared to >500 mL IV fluid was not significant (RR = 0.98 [0.87, 1.11]). The heterogeneity for all studies was high (I2 = 84%), but was low (I2 = 0%) with removal of two studies. Conclusion: The majority of studies did not find a relationship between the volume of prehospital IV fluids and in-hospital mortality. Study heterogeneity was low except for two studies: this may be explained by mortality only being recorded at emergency department discharge in one study, and the high rate of penetrating gunshot and stabbing wounds in the other. There is a paucity of high-quality RCTs on the topic, and many studies are at significant risk of bias. Further research is needed to delineate the best approach to IV fluid therapy in adult trauma patients.