The effectiveness of prehospital hypertonic saline for hypotensive trauma patients: a systematic review and meta-analysis

I. E. Blanchard, A. Ahmad, K. L. Tang, P. E. Ronksley, D. Lorenzetti, G. Lazarenko, E. S. Lang, C. J. Doig, H. T. Stelfox

The optimal prehospital fluid for the treatment of hypotension is unknown. Hypertonic fluids may increase circulatory volume and mute the pro-inflammatory response of the body to injury and illness. The purpose of this systematic review is to determine whether in patients presenting with hypotension in the prehospital setting (population), the administration of hypertonic saline (intervention), compared to an isotonic fluid (control), improves survival to hospital discharge (outcome). Searches were conducted in Medline, Embase, CINAHL, and CENTRAL from the date of database inception to November, 2016, and included all languages. Two reviewers independently selected randomized control trials of hypotensive human participants administered hypertonic saline in the prehospital setting. The comparison was isotonic fluid, which included normal saline, and near isotonic fluids such as Ringer's Lactate. Assessment of study quality was done using the Cochrane Collaborations' risk of bias tool and a fixed effect meta-analysis was conducted to determine the pooled relative risk of survival to hospital discharge. Secondary outcomes were reported for fluid requirements, multi-organ failure, adverse events, length of hospital stay, long term survival and disability. Of the 1160 non-duplicate citations screened, thirty-eight articles underwent full-text review, and five trials were included in the systematic review. All studies administered a fixed 250 ml dose of 7.5% hypertonic saline, except one that administered 300 ml. Two studies used normal saline, two Ringer's Lactate, and one Ringer's Acetate as control. Routine care co-interventions included isotonic fluids and colloids. Five studies were included in the meta-analysis (n = 1162 injured patients) with minimal statistical heterogeneity (I 2  = 0%). The pooled relative risk of survival to hospital discharge with hypertonic saline was 1.02 times that of patients who received isotonic fluids (95% Confidence Interval: 0.95, 1.10). There were no consistent statistically significant differences in secondary outcomes. There was no significant difference in important clinical outcomes for hypotensive injured patients administered hypertonic saline compared to isotonic fluid in the prehospital setting. Hypertonic saline cannot be recommended for use in prehospital clinical practice for the management of hypotensive injured patients based on the available data. PROSPERO registration # CRD42016053385 .