Abstract
Background: Quality improvement for the surgical care of trauma patients has focused predominantly on interventions within the first 24 hours after injury and has yielded significant improvements outcomes in recent decades. However, many trauma patients require multiple procedures coordinated with a variety of subspecialty services during their initial hospitalization, and late outcomes after traumatic injury are often driven by management of medical comorbidities.
Methods: This scoping review seeks to determine what is known about best practices for fluid management and resuscitation later in trauma care after hemostasis has been achieved. A standardized three-stage search revealed 41 papers for review, of which 12 met criteria.
Results: After the post-hemostatic period (>24 hours after injury), the incidence of multiple organ failure among trauma patients remains high, as does morbidity and mortality among these patients. Data from the orthopedic literature suggest that lower hemoglobin transfusion triggers might be well-tolerated later in the post-hemostatic period, and repeat doses of tranexamic acid (TXA) are associated with decreased intraoperative blood loss but not increased incidence of venous thromboembolism (VTE). Balanced crystalloids are associated with lower volumes of fluid required, and, if transfusion is required, whole blood is not associated with increased transfusion reactions. Finally, for those trauma patients who survive to ICU admission, a composite score of common biometric data and laboratory results may predict which trauma patients have higher resuscitation needs, and providing balanced crystalloids early in ICU admission is associated with a lower volume of resuscitation required.
Conclusions: Relatively few publications address ongoing resuscitation and fluid management for trauma patients in the post-hemostatic period (>24 hours after injury). Better outcomes are observed when balanced crystalloids are used early in ongoing resuscitation after hemostasis. Multiple organ failure (MOF) after trauma remains a dangerous syndrome, and the lack of a standardized definition hinders future research to define best practices for fluid management for patients with and without MOF. The study was limited by the lack of standardized terminology and approach to studying outcomes later in trauma care after hemostasis has been achieved.