Research Of Damage Control Resuscitation For Severe Traumatic Hemorrhage

Damage control resuscitation(DCR) is derived from damage control surgery(DCS), and its basic principles include effective hemorrhage control, early blood products transfusion, reduction in crystalloid fluid administration and permissive hypotension in severe trauma patients to address coagulopathy, acidosis and hypothermia. Limited fluid resuscitation and hemostatic resuscitation are the two important parts in DCR. Limited fluid resuscitation is mainly for uncontrolled traumatic hemorrhagic shock and put emphasis on maintenance of blood pressure in a subnormal range before the active bleeding is controlled to avoid dilutional coagulopathy which is caused by aggressive administration of fluid. Hemostatic resuscitation emphasizes the early detection of coagulation function damage, maintain of the ratio of plasma to red blood cell which approximates the physiological proportion and combination use of adjunct drug to correct coagulopathy. With the enrichment and development of DCR, the treatment models of severe trauma have gone through enormous changes in the past decade. [Objective]To evaluate the therapeutic efficacy of limited fluid resuscitation for uncontrolled traumatic hemorrhagic shock and different ratios of plasma to red blood cell transfused in hemostatic resuscitation for severe traumatic hemorrhage and provide evidence for the clinical treatment of severe traumatic hemorrhage. [Methods]Researches which compared therapeutic efficacy of limited fluid resuscitation and conventional fluid resuscitation for uncontrolled traumatic hemorrhagic shock and different ratios of plasma to red blood cell transfused in hemostatic resuscitation for severe traumatic hemorrhage were searched in Pub Med, EMbase and The Cochrane Library from inception to March 2016. Cochrane handbook(version 5.1.0) and Newcastle-Ottawa Scale(NOS) were utilized to assess the risk of bias of randomized controlled trail(RCT) and case control study(CCS). Meta-analysis was performed with Rev Man5.3, and GRADEpro3.6.1 was used to rate the level of evidence.[Results]1 Limited fluid resuscitation compared with conventional fluid resuscitation for uncontrolled traumatic hemorrhagic shock.1.1 Meta-analysis of overall mortality. Overall mortality was significantly lower in the limited fluid resuscitation group [risk ratio(RR) =0.77, 95% confidence interval(CI)(0.62, 0.95), P=0.01; n=984, GRADE rating: moderate]. According to the resuscitation modes, the included researches were divided into two subgroups(the hypotensive resuscitation subgroup and delayed resuscitation subgroup). The meta-analysis of the subgroups showed that there was no significant difference in overall mortality between limited fluid resuscitation group and conventional fluid resuscitation group. According to the proportion of penetrating trauma, the included researches were divided into two subgroups(the high ratio of penetrating trauma subgroup and low ratio of penetrating trauma subgroup). The meta-analysis of the subgroups showed that there was no significant difference in overall mortality in low ratio of penetrating trauma group and overall mortality was significantly lower in limited fluid resuscitation group in high ratio of penetrating trauma subgroup [RR=0.79, 95% CI(0.64, 0.99), P=0.04]. According to the types of research, the included researches were divided into two subgroups [the RCT subgroup and the quasi-randomized controlled trail(q RCT) subgroup]. The meta-analysis of the subgroups showed that there was no significant difference in overall mortality between limited fluid resuscitation group and conventional fluid resuscitation group.1.2 Meta-analysis of 24 h mortality. Twenty-four hour mortality was significantly lower in limited fluid resuscitation group [RR=0.47, 95% CI(0.24, 0.91), P=0.03; n=281, GRADE rating: moderate].2 Different ratios of plasma to red blood cell transfused in hemostatic resuscitation for severe traumatic hemorrhage.2.1 Meta-analysis of overall mortality with a cut off at ?1:1. Overall mortality was significantly lower in the high ratio group [odd ratio(OR) =0.54, 95% CI(0.36, 0.81), P=0.003; n=2172, GRADE rating: very low]. According to the types of research, the included researches were divided into two subgroups(the RCT subgroup and the CCS subgroup). The meta-analysis of the subgroups showed that there was no significant difference in overall mortality between high ratio group and low ratio group in RCT subgroup and overall mortality was significantly lower in high ratio group in CCS subgroup [OR=0.47, 95% CI(0.31, 0.72), P=0.0004]. There was no significant difference in overall mortality between the 1:1 group and the 1:2 group and overall mortality was significantly lower in 1:1 group compared with 1:4 group [OR=0.30, 95% CI(0.20, 0.46), P<0.00001].2.2 Meta-analysis of overall mortality with a cut off at ?1:2. Overall mortality was significantly lower in high ratio group [OR=0.54, 95% CI(0.41, 0.70), P<0.00001; n=4850, GRADE rating: very low].2.3 Meta-analysis of overall mortality with a cut off at ?1:3. Overall mortality was significantly lower in high ratio group [OR=0.34, 95% CI(0.21, 0.56), P<0.0001; n=1517, GRADE rating: low].2.4 Meta-analysis of 24 h mortality with a cut off at ?1:1. Twenty-four hour mortality was significantly lower in high ratio group [OR=0.51, 95% CI(0.36, 0.71), P<0.00001; n=1393, GRADE rating: very low].2.5 Meta-analysis of 24 h mortality with a cut off at ?1:2. Twenty-four hour mortality was significantly lower in high ratio group [OR=0.41, 95% CI(0.29, 0.59), P<0.00001; n=4246, GRADE rating: low].2.6 Meta-analysis of 24 h mortality with a cut off at ?1:3. Twenty-four hour mortality was significantly lower in high ratio group [OR=0.28, 95% CI(0.19, 0.41), P<0.00001; n=752, GRADE rating: low]. [Conclusions]1 Limited fluid resuscitation can reduce overall mortality and 24 h mortality in uncontrolled traumatic hemorrhagic shock patients, and the GRADE rating is moderate. Further research should be done to explore the therapeutic efficacy of limited fluid resuscitation for uncontrolled traumatic hemorrhagic shock patients in different models(hypotensive resuscitation and delayed resuscitation) and in different types of trauma(blunt trauma and penetrating trauma).2 High ratio of plasma to red blood cell(with a cut off at ?1:1, ?1:2 and ?1:3) in hemostatic resuscitation can reduce overall mortality and 24 h mortality in severe traumatic hemorrhage patients, and the GRADE rating is low to very low. The optimal ratio of plasma to red blood cell need to be validated by more high quality RCTs.