Early vasopressor use following traumatic injury: a systematic review

TY - JOUR

T1 - Early vasopressor use following traumatic injury

T2 - a systematic review

AU - Hylands, Mathieu

AU - Toma, Augustin

AU - Beaudoin, Nicolas

AU - Frenette, Anne Julie

AU - D'Aragon, Frédérick

AU - Belley-Côté, Émilie

AU - Charbonney, Emmanuel

AU - Møller, Morten Hylander

AU - Laake, Jon Henrik

AU - Vandvik, Per Olav

AU - Siemieniuk, Reed Alexander

AU - Rochwerg, Bram

AU - Lauzier, François

AU - Green, Robert S

AU - Ball, Ian

AU - Scales, Damon

AU - Murthy, Srinivas

AU - Kwong, Joey S W

AU - Guyatt, Gordon

AU - Rizoli, Sandro

AU - Asfar, Pierre

AU - Lamontagne, François

N1 - © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

PY - 2017/11/1

Y1 - 2017/11/1

N2 - OBJECTIVES: Current 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.DESIGN: Systematic review.DATA SOURCES: We 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 STUDIES: Randomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury.RESULTS: Of 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.CONCLUSIONS: Existing 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.

AB - OBJECTIVES: Current 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.DESIGN: Systematic review.DATA SOURCES: We 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 STUDIES: Randomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury.RESULTS: Of 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.CONCLUSIONS: Existing 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.

U2 - 10.1136/bmjopen-2017-017559

DO - 10.1136/bmjopen-2017-017559

M3 - Review

C2 - 29151048

SN - 2044-6055

VL - 7

JO - BMJ Open

JF - BMJ Open

IS - 11

M1 - e017559

ER -