A Systematic Review and Meta-Analysis of Permissive Hypotension vs. Conventional Resuscitation in Adult Trauma Patients with Hemorrhagic Injury
CCCF ePoster library. Tran A. Oct 3, 2017; 198175; 56
Alexandre Tran
Alexandre Tran
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A Systematic Review and Meta-Analysis of Permissive Hypotension vs. Conventional Resuscitation in Adult Trauma Patients with Hemorrhagic Injury

Alexandre Tran1, Jeffrey Yates1, 2, Aaron Lau3, Jacinthe Lampron3, Maher Matar3

  1. Clinical Epidemiology Program, University of Ottawa, Ottawa, Canada; 2. Faculty of Medicine, University of Ottawa, Ottawa, Canada; 3. Division of General Surgery, The Ottawa Hospital, Ottawa, Canada; 4. Department of Anesthesiology, University of British Columbia, Vancouver, Canada

Introduction: Aggressive fluid resuscitation in trauma may promote deleterious effects as increased hydrostatic pressure may disrupt and dislodge fresh hemostatic clots. In addition, aggressive resuscitation may result in dilutional coagulopathy and hypothermia. Animal studies have suggested that permissive hypotension maintains appropriate cardiac output and organ perfusion, reduces bleeding and improves mortality. 
Objectives: The objective of this review was to assess the efficacy and safety of permissive hypotensive resuscitation in adult trauma patients with hemorrhagic shock.
Methods: We searched the MEDLINE and EMBASE databases from inception to May 2017 for randomized controlled trials evaluating the use of permissive hypotension vs. conventional resuscitation in adult blunt or penetrating trauma patients with hemorrhagic 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 such as sepsis, coagulopathy or acute kidney injury. Pooling of study data for the primary outcome of mortality was performed with a random-effects model. Secondary outcome data were deemed inappropriate for pooling due to clinical heterogeneity and are presented narratively in tables.
Results: We screened 700 abstracts, from which five randomized trials evaluating 1152 patients were included in this review. 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 evaluated mixed blunt and penetrating injury patients. Four of the five trials demonstrated a survival benefit for 30-day or in-hospital mortality when utilizing a permissive hypotension resuscitation strategy, although three study findings were not statistically significant due to limitations in sample size. The pooled odds ratio was 0.70 (95% CI 0.53 to 0.92), suggesting a significant survival benefit for permissive hypotension. Patients with permissive hypotension received fewer blood products and had lower estimated blood loss volumes. Similar rates of sepsis, coagulopathy and acute kidney injury were noted between permissive and conventional resuscitation groups.
Conclusion: Permissive hypotension may offer a survival benefit for over conventional resuscitation for trauma patients with hemorrhagic injury. It may additionally reduce blood loss and blood product utilization. There was no evidence of significant reduction in complications such as sepsis, coagulopathy or acute kidney injury.
PROSPERO Registration: CRD42017070526

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