title: Limited volume resuscitation in hypotensive elderly multiple trauma is safe and prevents early clinical dilutive coagulopathy -- a matched-pair analysis from TraumaRegister DGU(®).
abstract: BACKGROUND
  The use of permissive hypotension includes a restrained volume preclinical therapy. However, in the elderly patients, this approach has raised concerns because of the increased cardiovascular risk profile and a higher incidence of hypertension under normal conditions. The aim of the study was to examine whether preclinical administration of restrictive volume therapy in the elderly patient can be safe.
  
  
  METHODS
  A retrospective matched-pair analysis with the data set of the TraumaRegister DGU(®) (TR-DGU) was performed based on data of 176 pairs of totally 67,000 patients. To address elderly potentially bleeding patients without major brain injury the following inclusion criteria were chosen: patients ≥ 60 years, ISS ≥ 16, AIS head<4, preclinical blood pressure between 60 and 100 mmHg and recorded preclinical volume administration. Patients that met the inclusion criteria (908) were divided into two groups: pre-clinical volume resuscitation ≤ 1000 ml (=low volume) and >1000 ml (high volume). Patients with high- and low-volume fluid replacement were matched according to the following criteria: age group, gender, date of the accident ± 5 years, ISS, GCS, preclinical intubation, ground-/air-transport, pre-clinical blood pressure.
  
  
  RESULTS
  Preclinical volume resuscitation showed a difference of about 1000 ml between the "low volume" and "high volume" group. The "low volume" group showed a significantly elongated prothrombin time. The amount of blood products given in the emergency department was not significantly different. The ventilation was 2 days shorter in the "low volume", although the number of patients with severe thoracic trauma was greater in this group. The length of stay in the ICU differed by 3 days in favour of the "low volume" group. The overall mortality was almost the same in both groups.
  
  
  CONCLUSIONS
  Based on these data it can be assumed that the lower preclinical volume administration has a positive effect on the initial coagulation status in elderly patients. In spite of some limitations such as low number of matched pairs, we draw the cautious conclusion that a restrictive preclinical volume therapy is safe and also indicated in elderly patients.
authors.affiliation: Heinrich Heine University Hospital Duesseldorf, Department of Trauma and Handsurgery, Moorenstr. 5, 40225 Duesseldorf, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Leenen
authors.affiliation: Heinrich Heine University Hospital Duesseldorf, Department of Trauma and Handsurgery, Moorenstr. 5, 40225 Duesseldorf, Germany. Electronic address: armin.scholz@med.uni-duesseldorf.de.
authors.forename: A
authors.initials: A
authors.lastname: Scholz
authors.affiliation: Institute for Research in Operative Medicine (IFOM), Faculty of Medicine, Witten/Herdecke University, Germany.
authors.forename: R
authors.initials: R
authors.lastname: Lefering
authors.affiliation: Heinrich Heine University Hospital Duesseldorf, Department of Trauma and Handsurgery, Moorenstr. 5, 40225 Duesseldorf, Germany.
authors.forename: S
authors.initials: S
authors.lastname: Flohé
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000209:etiology / Q000517:prevention & control*; D004632:Emergency Medical Services; D005260:Female; D005440:Fluid Therapy / Q000379:methods; D005858:Germany / Q000453:epidemiology; D006801:Humans; D007022:Hypotension / Q000150:complications* / Q000209:etiology / Q000401:mortality; D015601:Injury Severity Score; D007440:Intubation / Q000379:methods; D008297:Male; D016555:Matched-Pair Analysis; D009104:Multiple Trauma / Q000150:complications / Q000401:mortality / Q000628:therapy*; D012042:Registries; D012151:Resuscitation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome
keywords: Coagulopathy; Elderly patient; Permissive hypotension; Trauma; Trauma register; Volume replacement