Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma

Abstract

Achieving a balance between organ perfusion and hemostasis is critical for optimal fluid resuscitation in patients with severe trauma. The concept of "permissive hypotension" refers to managing trauma patients by restricting the amount of resuscitation fluid and maintaining blood pressure in the lower than normal range if there is continuing bleeding during the acute period of injury. This treatment approach may avoid the adverse effects of early, high-dose fluid resuscitation, such as dilutional coagulopathy and acceleration of hemorrhage, but does carry the potential risk of tissue hypoperfusion. Current clinical guidelines recommend the use of permissive hypotension and controlled resuscitation. However, it is not mentioned which subjects would receive most benefit from this approach, when considering factors such as age, injury mechanism, setting, or the presence or absence of hypotension. Recently, two randomized clinical trials examined the efficacy of titrating blood pressure in younger patients with shock secondary to either penetrating or blunt injury; in both trials, overall mortality was not improved. Another two major clinical trials suggest that controlled resuscitation may be safe in patients with blunt injury in the pre-hospital setting and possibly lead to improved outcomes, especially in patients with pre-hospital hypotension. Some animal studies suggest that hypotensive resuscitation may improve outcomes in subjects with penetrating injury where bleeding occurs from only one site. On the other hand, hypotensive resuscitation in blunt trauma may worsen outcomes due to tissue hypoperfusion. The influence of these approaches on coagulation has not been sufficiently examined, even in animal studies. The effectiveness of permissive hypotension/ hypotensive resuscitation and restricted/controlled resuscitation is still inconclusive, even when examining systematic reviews and meta-analyses. Further investigation is needed to elucidate the effectiveness of these approaches, so as to develop improved treatment strategies which take into account coagulopathy in the pathophysiology of trauma.

Heterogeneous emergency department management of published recommendation defined hypotension in patients with acute traumatic spinal cord injury: A multi‐centre overview

“…No association with concomitant head, chest or abdominal injury was found. Permissive hypotensive resuscitation has become an accepted approach to damage control resuscitation in patients with multiple severe injuries . Although it is not a recommended resuscitative strategy in traumatic brain or spinal cord injury, it could explain some of the failure to increase BP in some patients in the present study and may be an area for further examination.…”

An evaluation of the relationship between traumatic injuries and the development of contrast-associated acute kidney injury

“…In this setting the provision of fluids may be restricted, limiting the magnitude of volume expansion that may otherwise be targeted. 26–28 The potential limitations of fluid administration in select patients, however, reinforce the importance of the findings of this logistic regression model which suggests that the risk of developing CAAKI may also be strongly influenced by other modifiable risk factors and traumatic injuries.…”

“…Accordingly, recommendations concerning the proper volume of IV fluid to administer are often vague; however, a strategy aimed at maintaining an optimal fluid balance and preventing hypovolemia prior to contrast administration should be consistently applied. 23,[26][27][28] Exceptions to this practice may occur, for example, in patients who present with hemorrhagic complications from trauma resulting in the implementation of permissive hypotension. In this setting the provision of fluids may be restricted, limiting the magnitude of volume expansion that may otherwise be targeted.…”

Pre-hospital trauma care in Switzerland and Germany: do they speak the same language?

“…Thereby, more liberal pre-hospital fluid administration seems to be associated with more adequate restoration of hemodynamics during the pre-hospital phase. This is, however, in contrast with the present heavily propagated principles of limited volume resuscitation and permissive hypotension in trauma [26,27].…”