title: Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma).
abstract: BACKGROUND
  The role of fluids in trauma resuscitation is controversial. We compared resuscitation with 0.9% saline vs hydroxyethyl starch, HES 130/0.4, in severe trauma with respect to resuscitation, fluid volume, gastrointestinal recovery, renal function, and blood product requirements.
  
  
  METHODS
  Randomized, controlled, double-blind study of severely injured patients requiring >3 litres of fluid resuscitation. Blunt and penetrating trauma were randomized separately. Patients were followed up for 30 days.
  
  
  RESULTS
  A total of 115 patients were randomized; of which, 109 were studied. For patients with penetrating trauma (n=67), the mean (sd) fluid requirements were 5.1 (2.7) litres in the HES group and 7.4 (4.3) litres in the saline group (P<0.001). In blunt trauma (n=42), there was no difference in study fluid requirements, but the HES group required significantly more blood products [packed red blood cell volumes 2943 (1628) vs 1473 (1071) ml, P=0.005] and was more severely injured than the saline group (median injury severity score 29.5 vs 18; P=0.01). Haemodynamic data were similar, but, in the penetrating group, plasma lactate concentrations were lower over the first 4 h (P=0.029) and on day 1 with HES than with saline [2.1 (1.4) vs 3.2 (2.2) mmol litre⁻¹; P=0.017]. There was no difference between any groups in time to recovery of bowel function or mortality. In penetrating trauma, renal injury occurred more frequently in the saline group than the HES group (16% vs 0%; P=0.018). In penetrating trauma, maximum sequential organ function scores were lower with HES than with saline (median 2.4 vs 4.5, P=0.012). No differences were seen in safety measures in the blunt trauma patients.
  
  
  CONCLUSIONS
  In penetrating trauma, HES provided significantly better lactate clearance and less renal injury than saline. No firm conclusions could be drawn for blunt trauma.
  
  
  BACKGROUND
  ISRCTN 42061860.
authors.affiliation: Department of Anaesthesia, Groote Schuur Hospital and Faculty of Health Sciences, University of Cape Town, Observatory, Cape Town, Western Cape 7925, South Africa. mike.james@uct.ac.za
authors.forename: M F M
authors.initials: MF
authors.lastname: James
authors.forename: W L
authors.initials: WL
authors.lastname: Michell
authors.forename: I A
authors.initials: IA
authors.lastname: Joubert
authors.forename: A J
authors.initials: AJ
authors.lastname: Nicol
authors.forename: P H
authors.initials: PH
authors.lastname: Navsaria
authors.forename: R S
authors.initials: RS
authors.lastname: Gillespie
mesh_terms: D058186:Acute Kidney Injury / Q000097:blood / Q000150:complications; D000293:Adolescent; D000328:Adult; D015415:Biomarkers / Q000097:blood; D004311:Double-Blind Method; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D005500:Follow-Up Studies; D041981:Gastrointestinal Tract / Q000503:physiopathology; D006801:Humans; D006895:Hydroxyethyl Starch Derivatives / Q000097:blood / Q000627:therapeutic use*; D015601:Injury Severity Score; D007668:Kidney / Q000187:drug effects* / Q000503:physiopathology; D007677:Kidney Function Tests; D019344:Lactic Acid / Q000097:blood*; D008297:Male; D008875:Middle Aged; D010952:Plasma Substitutes / Q000378:metabolism / Q000627:therapeutic use*; D012151:Resuscitation / Q000379:methods*; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage / Q000378:metabolism; D016019:Survival Analysis; D014950:Wounds, Penetrating / Q000097:blood / Q000150:complications*; D055815:Young Adult
chemical_list: D015415:Biomarkers; D006895:Hydroxyethyl Starch Derivatives; D010952:Plasma Substitutes; D012462:Saline Solution, Hypertonic; D019344:Lactic Acid