title: 10-Year trend in crystalloid resuscitation: Reduced volume and lower mortality.
abstract: BACKGROUND
  Liberal emergency department (ED) resuscitation after trauma may lead to uncontrolled hemorrhage, reduced organ perfusion, and compartment syndrome. Recent guidelines reduced the standard starting point for crystalloid resuscitation from 2 L to 1 L and emphasized "balanced" resuscitation. The purpose of this study was to characterize how an urban, Level 1 trauma center has responded to changes in crystalloid resuscitation practices over time and to describe associated patient outcomes.
  
  
  METHODS
  This is a retrospective review of trauma patients who sustained moderate to severe injury (ISS > 9) and received crystalloid resuscitation in the ED during 1/2004-12/2013 at an urban, Level 1 trauma center. Patient data collected included age, gender, Glasgow Coma Scale (GCS) score, initial systolic blood pressure (SBP), mechanism of injury, regional Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), volume of blood products and crystalloids administered in the ED. Patients who received <2 L of crystalloid were considered low-volume while those who received ≥2 L were high-volume patients. Clinical characteristics and outcomes were compared between high- and low-volume cohorts, and multivariate regression was used to adjust for confounders. Trend analysis examined changes in variables over time.
  
  
  RESULTS
  1571 moderate to severely injured patients received crystalloid resuscitation; 1282 (82%) were low-volume and 289 (18%) were high-volume. Compared to high-volume patients, low-volume patients presented with a higher median SBP (134 vs. 122 mmHg, p < 0.001) and GCS (15 vs. 14, p < 0.001). Low-volume patients also had lower median ISS (15 vs. 19, p < 0.001). Unadjusted mortality was lower in the low-volume cohort (7% vs. 19%, p < 0.001). Multivariate analysis demonstrated that high-volume patients had increased odds of mortality compared to low-volume patients (AOR 1.88, p = 0.008). Decreased rates of high-volume resuscitation and overall mortality were demonstrated over the 10-year study period.
  
  
  CONCLUSIONS
  The observed decrease in high-volume crystalloid resuscitations in the ED paralleled a reduction in mortality over the ten-year period. In addition, adjusted mortality was higher in those receiving high-volume resuscitation.
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: Megan.Harada@gmail.com.
authors.forename: Megan Y
authors.initials: MY
authors.lastname: Harada
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: Ara.Ko@cshs.org.
authors.forename: Ara
authors.initials: A
authors.lastname: Ko
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: Galinos.Barmparas@cshs.org.
authors.forename: Galinos
authors.initials: G
authors.lastname: Barmparas
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: Eric.Smith@cshs.org.
authors.forename: Eric J T
authors.initials: EJ
authors.lastname: Smith
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: bansuripatel93@gmail.com.
authors.forename: Bansuri K
authors.initials: BK
authors.lastname: Patel
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: Navpreet.Dhillon@cshs.org.
authors.forename: Navpreet K
authors.initials: NK
authors.lastname: Dhillon
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: Gretchen.Thomsen@cshs.org.
authors.forename: Gretchen M
authors.initials: GM
authors.lastname: Thomsen
authors.affiliation: Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA. Electronic address: Eric.Ley@cshs.org.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Ley
mesh_terms: D000328:Adult; D000077324:Crystalloid Solutions; D004334:Drug Administration Schedule; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015601:Injury Severity Score; D007552:Isotonic Solutions / Q000008:administration & dosage / Q000627:therapeutic use*; D015141:Los Angeles; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D012151:Resuscitation; D012189:Retrospective Studies; D014193:Trauma Centers; D016896:Treatment Outcome; D019037:Urban Health Services
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions
keywords: Blood transfusion; Crystalloids; Damage-control resuscitation; Mortality; Trauma