Salines, osmoles and albumin.
In 2004, two large randomised multi-centre Australian clinical trials provided new information concerning optimal resuscitation for patients with traumatic brain injury (TBI). One examined hypertonic saline (HTS) and the other, albumin versus saline.( )For the first time in a randomised trial, hypertonic saline was tested for pre-hospital resuscitation of hypotensive patients with traumatic brain injury, and for the first time a resuscitation fluid trial measured long term neurological function as the primary outcome. Despite many potential advantages which may have much greater relevance in the hospital setting, in the paramedic based VICn trauma system, HTS did not improve neurological outcome compared to conventional pre-hospital fluid protocols. Nevertheless, HTS resuscitation was confirmed to be safe in TBI patients and may find application in future pre-hospital military settings where fluid weight is of primary importance. The very large randomised SAFE trial found that there was no difference in 28 day survival between albumin and saline resuscitation for intensive care patients, and by providing very high quality data, this study has largely settled a generation old controversy. Intriguingly however, the SAFE study also reported that within a subgroup of 492 patients with TBI, 28 day survival was superior in patients receiving saline. This subgroup result was not considered definitive, but a post hoc examination of the TBI patients currently in progress by the SAFE investigators, is expected to provide further guidance for clinicians. In the meanwhile, and until more high quality data is available, many clinicians are likely to prefer crystalloid resuscitation for trauma patients, and especially for trauma patients with brain injury.
Trauma Intensive Care, The Alfred Hospital, Melbourne, VIC 3181, Australia j.cooper@alfred.org.au.
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