Crystalloid resuscitation is associated with decreased treatment delays and improved systolic blood pressures in a blood-constrained setting

Abstract

Objectives: We analyzed resuscitation practices in Cameroonian patients with trauma as a first step toward developing a context-appropriate resuscitation protocol. We hypothesized that more patients would receive crystalloid-based (CB) resuscitation with a faster time to administration than blood product (BL) resuscitation. Methods: We included patients enrolled between 2017 and 2019 in the Cameroon Trauma Registry (CTR). Patients presenting with hemorrhagic shock (systolic blood pressure (SBP) <100 mm Hg and active bleeding) were categorized as receiving CB, BL, or no resuscitation (NR). We evaluated differences between cohorts with the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. We compared time to treatment with the Wilcoxon rank sum test. Results: Of 9635 patients, 403 (4%) presented with hemorrhagic shock. Of these, 278 (69%) patients received CB, 39 (10%) received BL, and 86 (21%) received NR. BL patients presented with greater injury severity (Highest Estimated Abbreviated Injury Scale (HEAIS) 4 BL vs 3 CB vs 1 NR, p<0.001), and lower median hemoglobin (8.0 g/dL BL, 11.4 g/dL CB, 10.6 g/dL NR, p<0.001). CB showed greater initial improvement in SBP (12 mm Hg CB vs 9 mm Hg BL vs 0 NR mm Hg, p=0.04) compared with BL or no resuscitation, respectively. Median time to treatment was lower for CB than BL (12 vs 131 min, p<0.01). Multivariate logistic regression adjusted for injury severity found no association between resuscitation type and mortality (CB adjusted OR (aOR) 1.28, p=0.82; BL aOR 1.05, p=0.97). Conclusions: CB was associated with faster treatment, greater SBP elevation, and similar survival compared with BL in Cameroonian patients with trauma with hemorrhagic shock. In blood-constrained settings, treatment delays associated with blood product transfusion may offset the physiologic benefits of an early BL strategy. CB prior to definitive hemorrhage control in this resource-limited setting may be a necessary strategy to optimize perfusion pressure. Level of evidence and study type: III, retrospective study.