Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part I

ResearchBlogging.org

Also posted over at Paramedicine 101 (now at EMS Blogs) and at Research Blogging. Go check out the rest of the excellent material at these sites.

This is discussed in Prehospital administration of IV fluids to trauma patients: EMS Research Episode 5.

CONCLUSIONS: The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.[1]

That is the conclusion posted in the abstract available from PubMed. For many people, this may be all that they will read. Sometimes the full text is available for free, so a subscription is not required to read the full text. Even so, most people with access to the full article may not read it.

We expect the PubMed abstract to provide the important information.

In this case, we would be wrong.

This study does not look at Prehospital Intravenous Fluid Administration.

Prehospital IV Starts are Associated With Higher Mortality in Trauma Patients.

That would improve the accuracy of the title, but even that is not supportable.

We hypothesize that trauma patients receiving prehospital IV catheter placement (with or without IV fluids) have higher mortality than trauma patients who did not receive an IV or fluids.[1]

But that is not the way this is being reported in the media, including medical media.

The primary independent variable was defined as prehospital IV. The majority of patients with the word “intravenous” or “IV” in the prehospital procedure file of the NTDB were coded as having received “intravenous fluids.” However, there were many different terms reported along the “intravenous” continuum and we could not definitively differentiate IV fluid administration versus IV catheter placement alone. Therefore, we grouped both all patients under the heading of “pre-hospital IV”.[1]

The very next sentence is –

We performed a descriptive analysis of our dependent and independent variables, and we conducted an unadjusted analysis that included a comparison of mortality rates among all patients with versus without prehospital IV fluids.[1]

with versus without prehospital IV fluids.

They don’t even know which patients received fluids.

They don’t know anything about the amount of fluids that might have been given.

All things are poison and nothing is without poison, only the dose permits something not to be poisonous. – Paracelsus.

We know nothing about the dose of fluids.

Was it 10 ml/patient?

Was it 100 ml/patient?

Was it 1,000 ml/patient?

Was it 10,000 ml/patient?

Your guess is as good as mine.

Your guess is probably also as good as the guesses of the authors of this study.

How did the media report this?

Giving IV fluids on scene might raise death risk for trauma victims
Updated 1/10/2011 4:52 PM
By Alan Mozes, HealthDay
USA Today
Article

The above article is also published at Bloomberg Business Week.

IV fluids may not always be good for accident victims, study finds
January 04, 2011
By Thomas H. Maugh II
Los Angeles Times
Article

These articles do not contain any explanation that the researchers have no idea which patients received fluids or how much fluid. Dr. Haut was interviewed and presented his information as if the abstract were accurate and informative. It is neither.

A late entry – 03/01/11 is the reporting by Medscape. This was not put on line after I wrote about it, but I missed it when I originally wrote this. Medscape is a web site edited by doctors, but even they did not seem to notice the flaws of this study.

From Medscape Medical News
Prehospital IV Fluids May Be Harmful for Trauma Victims
Medscape
Laurie Barclay, MD
January 20, 2011
Article

What about on line sources?

Prehospital Intravenous Fluids May Harm Trauma Patients
Mortality highest in patients with penetrating injuries, hypotension, or severe head injury

Modern Medicine
Article

Prehospital Intravenous Fluids May Harm Trauma Patients
Doctors Lounge
Article

Prehospital IV fluid administration
IVTEAM
Article

These essentially repeat only the information in the abstract, or they repeat small parts of the information in the abstract.

Did anybody get it right?

Pre-hospital iv and increased mortality
RESUS.me
Article

Does Fluid Resuscitation Harm Trauma Patients?
Skeptical Scalpel
Article

And the podcast I mentioned at the beginning –

Prehospital administration of IV fluids to trauma patients: EMS Research Episode 5
EMS Research Podcast
Podcast

Late entry – 02/21/11 Also covered by Dr. Chris Russi in the podcast Russi’s Research Review – Episode Two (Fluid Administration in Traumatic Injury Patients).

Part II and Part III will explain some of the problems with the study and some of the things to look for when evaluating the merits of a study.

Footnotes:

[1] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis.
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
Ann Surg. 2010 Dec 20. [Epub ahead of print]
PMID: 21178760 [PubMed – as supplied by publisher]

Full Text in PDF format from www.medicalscg.

Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, & Chang DC (2010). Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis. Annals of surgery PMID: 21178760

.

Comments

  1. Discussed this “study” on an internet forum when it first came out. These people need to quit calling themselves researchers.

    As you said, doesn’t differentiate the amount of fluids… but it also ignores the TYPE of fluid (NS? D5W? LR? Half NS? Albumin?)

    It also ignores the types of systems invovled (Rural? Urban? Suburban?)

    Heck, it even ignores the protocols/guidelines of said agencies. Do they have permissive hypotension? Do they just do 2 IVs and run fluids in till it’s koolaid? Etc etc.

    • Steve,

      Discussed this “study” on an internet forum when it first came out. These people need to quit calling themselves researchers.

      I would say that they need to do a better job of controlling their biases and recognize that the NTDB (National Trauma Data Bank®) is probably not accurate, although I expect continual progress and the NTDB may eventually be accurate.

      As you said, doesn’t differentiate the amount of fluids… but it also ignores the TYPE of fluid (NS? D5W? LR? Half NS? Albumin?)

      And the fluid might only be what is needed for KVO (about 15 ml/hour), or for a saline lock, or for medicine administration, such as pain medicine.

      It also ignores the types of systems invovled (Rural? Urban? Suburban?)

      Yes. The systems contributing are probably all of these.

      Heck, it even ignores the protocols/guidelines of said agencies. Do they have permissive hypotension? Do they just do 2 IVs and run fluids in till it’s koolaid? Etc etc.

      Again, these are probably from all types of systems. Dr. Toon mentioned the ROC (Resuscitation Outcomes Consortium) and the variation among those systems. The medical directors of the ROC systems are some of the most research-oriented medical directors in EMS, but even they have problems. The NTDB medical directors are not drawn from any particular group.

      It appears that spinal immobilization is under-reported, because I would be shocked to find that less than 10% of patients (transported to trauma centers for trauma) are not immobilized. I don’t think we should be immobilizing that large a percentage of patients, but I think that the reality is that we are immobilizing close to 10 times as many trauma patients as the NTDB suggests.

  2. I know I’m both beating the deceased equine and offering prayers to the believers, but this kind of shoddy crud goes on Every SINGLE DAY.

    Study excerpt/conclusion/abstract: “Eating peas linked to lung cancer in 60 yr old men”

    Media [including medical media]: “EATING PEAS CAUSES LUNG CANCER. BAN ON PEAS?”

    [We won’t even get into how I learned in 7th grade science class that “correlation != causation” but people with PhDs and MDs and other fancyshmancy degrees can’t seem to remember this.]

    What further drives me bonkers is when you read later a different “study” which refers to the snap conclusion from the first study: “We all know that pea consumption causes lung cancer [footnote-to-former-study], so we then concluded that…”

    And to make it even more fun, sometimes that study excerpt/conclusion/abstract? Is really just a press release. When you go to read the full “study” in a journal, it hasn’t been published yet, and when it finally is published it either doesn’t say that eating peas has anything to do with anything or talks about how in people with lung cancer, eating peas may have prolonged their life!

    GAHHH!!! BAD SCIENTISTS! NO GRANT!

  3. The surgeons I’ve discussed this with are of the opinion that patients who are in the 80-90 mm/Hg range of systolic BPs do better than those who are pumped up with non Oxygen carrying volume expanders. I haven’t had the time to discuss the whys of this, but the opinion seems to be pretty much unanimous.

    The data from Iraq and now Afghanistan is that volume infusion, like field intubation hurt, not help, chances of survival. What they observed in the case of intubation at least, is that the drugs we use to facilitate intubation out of the hospital cause a precipitous crash in BP and often the patient is in cardiac arrest when they arrive. The military standard now is to delay intubation until the patient is in the OR and prepped. I’m specifically referring to chest or abdominal wounds with uncontrollable hemorrhage, not extremity wounds where the bleeding can be controlled.

    In the next few years I expect to see some interesting papers coming out of this experience.

    If there is a benefit to war, it is that medical and technological advancement comes quickly. I’m not sure the cost is worth it, but that’s a different discussion.

    Of course the Holy Grail here would be an Oxygen carrying artificial blood that can be stored at room temperature.

    • Field intubation for abdo trauma?? Hell even ED intubation for abdominal trauma causes far more harm than good and should only be carried out if absolutely neccesary. Often the only thing preventing complete extravasation from their ruptured spleen is markedly raised abdominal pressure from a tense abdominal wall. RSI them and say goodbye to their other 2 litres of blood they were barely managing to retain in the circulation. When at all possible they should be wide awake up until im standing over them on an operating table with a few mls of thiopentone and the surgeon has them prepped and a scalpel and large artery ready to slash and clamp

Speak Your Mind