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08/09/2012

Moins remplir: Mieux ? Oui, MAIS

Restrictive fluid resuscitation in combination with damage control resuscitation: Time for adaptation.

Marquinn D et all. J Trauma Acute Care Surg. 2012;73: 674-678.

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Ce travail confirme l'intérêt d'une stratégie de remplissage vasculaire parcimonieuse dès lors qu'une réanimation et une chirurgie spécialisée moderne sont accessibles. Le collectif des patients est ici celui de traumatisés thoraciques sévères arrivant dans une structure spécialisée dans des délais très courts. De telles conditions ne sont pas forcément celles de la prise en charge de blessés de guerre pour qui les délais d'évacuation sont souvent plus élevés. Il n'en demeure pas moins que cette publication milite pour une politique de remplissage vasculaire raisonnée. On rappelle que la procédure du sauvetage au combat donne pour objectif la perception d'un pouls radial perceptible.

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BACKGROUND:

Damage control resuscitation (DCR) conveys a survival advantage in patients with severe hemorrhage. The role of restrictive fluid resuscitation (RFR) when used in combination with DCR has not been elucidated. We hypothesize that RFR, when used with DCR, conveys an overall survival benefit for patients with severe hemorrhage.

METHODS:

This is a retrospective analysis from January 2007 to May 2011 at a Level I trauma center. Inclusion criteria included penetrating torso injuries, systolic blood pressure less than or equal to 90 mm Hg, and managed with DCR and damage control surgery (DCS). There were two groups according to the quantity of fluid before DCS: (1) standard fluid resuscitation (SFR)greater than or equal to 150 mL of crystalloid; (2) RFR less than 150 mL of crystalloid. Demographics and outcomes were analyzed.

RESULTS:

Three hundred seven patients were included. Before DCS, 132 (43%) received less than 150 mL of crystalloids, grouped under RFR; and 175 (57%) received greater than or equal to 150 mL of crystalloids, grouped under SFR. Demographics and initial clinical characteristicswere similar between the study groups. Compared with the SFR group, RFR patients received less fluid preoperatively (129 mL vs. 2,757 mL; p G 0.001), exhibited a lower intraoperative mortality (9% vs. 32%; p G 0.001), and had a shorter hospital length of stay (13 vs. 18 days; p = 0.02). Patients in the SFR group had a lower trauma intensive care unit mortality (5 vs. 12%; p = 0.03) but exhibited a higher overall mortality. Patients receiving RFR demonstrated a survival benefit, with an odds ratio for mortality of 0.69 (95% confidence interval, 0.37Y0.91).

RFR.jpg

CONCLUSION:

To the best of our knowledge, this is the first civilian study that analyzes the impact of RFR in patients managed with DCR. Its use in conjunction with DCR for hypotensive trauma patients with penetrating injuries to the torso conveys an overall and early intraoperative survival benefit.

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