Early vasopressor use following traumatic injury: a systematic review

Abstract

ObjectivesCurrent guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction may be harmful, these agents may help reduce administration of potentially harmful resuscitation fluids. This systematic review aims to compare early vasopressor use to standard resuscitation in adults with trauma-induced shock.DesignSystematic review.Data sourcesWe searched MEDLINE, EMBASE, ClinicalTrials.gov and the Central Register of Controlled Trials from inception until October 2016, as well as the proceedings of 10 relevant international conferences from 2005 to 2016.Eligibility criteria for selecting studiesRandomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury.ResultsOf 8001 citations, we retrieved 18 full-text articles and included 6 studies (1 randomised controlled trial and 5 observational studies), including 2 published exclusively in abstract form. Across observational studies, vasopressor use was associated with increased short-term mortality, with unadjusted risk ratios ranging from 2.31 to 7.39. However, the risk of bias was considered high in these observational studies because patients who received vasopressors were systematically sicker than patients treated without vasopressors. One clinical trial (n=78) was too imprecise to yield meaningful results. Two clinical trials are currently ongoing. No study measured long-term quality of life or cognitive function.ConclusionsExisting data on the effects of vasopressors following traumatic injury are of very low quality according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. With emerging evidence of harm associated with aggressive fluid resuscitation and, in selected subgroups of patients, with permissive hypotension, the alternatives to vasopressor therapy are limited. Observational data showing that vasopressors are part of usual care would provide a strong justification for high-quality clinical trials of early vasopressor use during trauma resuscitation.Trial registration number CRD42016033437.

Risk factors for death of trauma patients admitted to an Intensive Care Unit

“…Vasoactive drugs may be transiently required in the presence of life-threatening hypotension (34) and early use may limit organ hypoperfusion and prevent multiple failure (28) . However, evidence identified in a systematic review of the early use of vasopressors after traumatic injury highlights that, in addition to the benefits, some damage from vasopressor therapy in the early phase of trauma is also reported, such as the risk of bleeding, coagulopathy, compartment syndrome, and surgical complications (34) .…”

The impact of early administration of vasopressor agents for the resuscitation of severe hemorrhagic shock following blunt trauma

“…Although many reports do not recommend the use of vasopressors for the resuscitation of trauma patients [12,13], some reports and guidelines have committed to the temporary use of vasopressors for life-threatening hemorrhagic shock to minimize fluid volume administered and maintain appropriate systemic perfusion [14,15]. Even in level 1 trauma centers, where any surgical or interventional radiographic procedures for the immediate control of bleeding and early activation of massive transfusion protocol (MTP) are always available, the effects and risks of vasopressor administration for severe hemorrhagic shock following trauma remain unclear [16][17][18][19].…”

The relationship between vasoactive-inotropic score and mortality in the adult patients with traumatic brain injury managed in the intensive care unit

“…The ages and gender ratios of the patients with severe TBI in a retrospective study were compliant with the results of our which may develop in the clinical course of refractory shock or transfusion of fluids and blood components are added to the fluid replacements. Because hypotension is commonly observed after TBI and it may affect survival (9,12,20). Mortality rate was found at 43.1% in this patient group in the present study.…”

“…There are a few studies which compared the efficacy of the vasopressors commonly used in the treatment of TBI and the outcomes of these studies are controversial (19). Besides, there is only a limited number of studies which investigated the use of vasopressors during the early stage of the resuscitation period in the traumatic brain injury patients with very high mortality rate (9). In the present study, the early stages of the TBI patients involving the first 48 hours in the ICU were analyzed.…”