title: Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation.
abstract: 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 characteristics were similar between the study groups. Compared with the SFR group, RFR patients received less fluid preoperatively (129 mL vs. 2,757 mL; p < 0.001), exhibited a lower intraoperative mortality (9% vs. 32%; p < 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, 0.37-0.91).
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Therapeutic study, level IV.
authors.affiliation: Department of Surgery,Section of Trauma and Critical Care Surgery, Tulane University Health Science Center, New Orleans, Louisiana 70112, USA.
authors.forename: Marquinn D
authors.initials: MD
authors.lastname: Duke
authors.forename: Chrissy
authors.initials: C
authors.lastname: Guidry
authors.forename: Jordan
authors.initials: J
authors.lastname: Guice
authors.forename: Lance
authors.initials: L
authors.lastname: Stuke
authors.forename: Alan B
authors.initials: AB
authors.lastname: Marr
authors.forename: John P
authors.initials: JP
authors.lastname: Hunt
authors.forename: Peter
authors.initials: P
authors.lastname: Meade
authors.forename: Norman E
authors.initials: NE
authors.lastname: McSwain
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Duchesne
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D015331:Cohort Studies; D003131:Combined Modality Therapy; D016001:Confidence Intervals; D016638:Critical Illness / Q000401:mortality / Q000628:therapy; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D005500:Follow-Up Studies; D006488:Hemostasis, Surgical / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D012151:Resuscitation / Q000379:methods* / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D017751:Safety Management; D012771:Shock, Hemorrhagic / Q000175:diagnosis / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D015996:Survival Rate; D013898:Thoracic Injuries / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D013908:Thoracotomy / Q000379:methods; D014193:Trauma Centers; D016896:Treatment Outcome; D014950:Wounds, Penetrating / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D055815:Young Adult