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These authors report an interim analysis of the first prospective randomized trial of intraoperative hypotensive resuscitation in patients. At a single level I trauma center, 90 patients with at least one episode of in-hospital systolic blood pressure ≤90 mm Hg who were undergoing laparotomy or thoracotomy for blunt (6 patients) or penetrating (84) trauma were randomized at entry to the operating room to have their mean arterial pressure (MAP) maintained at a target minimum of 50 mm Hg (low MAP) or 65 mm Hg (high MAP). Methods of achieving target levels were at the discretion of the anesthesiologist. MAPs that rose above the target were not lowered.
The low-MAP group received a significantly smaller amount of blood products (packed red blood cells, fresh frozen plasma, platelets) than the high-MAP group (1594 mL vs. 2898 mL) and had significantly lower mortality within 24 hours of admission to the intensive care unit (2.3% vs. 17.4%) and significantly lower mortality due to coagulopathy-associated postoperative hemorrhage (0 of 6 vs. 7 of 10). Mortality at 30 days did not differ significantly between the two groups (23% and 28%, respectively).
Morrison CA et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: Preliminary results of a randomized controlled trial. J Trauma 2011 Mar; 70:652.(http://dx.doi.org/10.1097/TA.0b013e31820e77ea)
Comment
This interim analysis suggests that maintaining a low MAP during intraoperative resuscitation in seriously ill trauma patients is safe, reduces use of blood products, and decreases the incidence of postoperative coagulopathy and the related consequence of death. If these promising findings hold in the final analysis, similar approaches should be undertaken in the field and the emergency department.