INEFFECTIVENESS OF ON-SITE INTRAVENOUS LINES - IS PREHOSPITAL TIME THE CULPRIT

The purpose of the present study was to test the association between o n-site intravenous fluid replacement and mortality in patients with se vere trauma, The effect of prehospital time on this association was al so evaluated. The design was that of an observational quasi-experiment al study comparing 217 patients who had on-site intravenous fluid repl acement (IV group) with an equal number of matched patients for whom t his intervention was not performed (no-IV group), The patients were in dividually matched on their Prehospital Index obtained at the scene an d were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital, The outcome meas ure of interest was mortality because of injury, The patients in the I V group had a significantly lower mean age (37 vs. 45 years; p < 0.001 ) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001), The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) wa s lower for the IV group, In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001), The m ortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001), Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospit al time, the use of on-site intravenous fluid replacement was associat ed with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To furth er evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and > 6 0 minutes, The adjusted odds ratios (95% confidence interval) for thes e strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08) , and 8.40 (1.27-54.69; p = 0.03), These results show that for prehosp ital times of less than 30 minutes, the use of on-site intravenous flu id replacement provides no benefit, and that for longer times, this in tervention is associated with significant increases in the risk of mor tality. The results of this observational study have shown that the us e of on-site intravenous fluid replacement is associated with an incre ase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times, Our finding s are consistent with the hypothesis that early intravenous fluid repl acement is harmful because it disrupts the normal physiologic response to severe bleeding, Although this evidence is against the implementat ion of on-site intravenous fluid replacement for severely injured pati ents, further studies including randomized controlled trials are requi red to provide a definitive answer to this question.