Fluid resuscitation in acute abdominal aortic aneurysm
Date First Published:
February 19, 2003
Last Updated:
February 19, 2003
Report by:
Fiona Lecky, Consultant (Manchester Royal Infirmary)
Search checked by:
TBC, Manchester Royal Infirmary
Three-Part Question:
In [adults with a ruptured abdominal aortic aneurysm] is [pre-operative intravenous fluid resuscitation more effective than withholding fluids] at [improving early and late survival rates]?
Clinical Scenario:
A 75 year old man presents to the Emergency department after collapsing at home with a sudden onset of back pain. On examination he is fully conscious, distressed with pain and has an expansile pulsating epigastric mass. His blood pressure is 80/40 mmHg. While you are waiting for the surgical consult you wonder whether it would be worthwhile administering a large I/V fluid bolus. This should raise his BP and may improve his tissue oxygen delivery. However, it may also increase bleeding from the aneurysm and will dilute clotting factors.
Search Strategy:
Medline 1966-10/98 using the OVID interface.
Search Details:
[exp aortic aneurysm OR aortic aneurysm ti.ab.sh.] AND [exp resuscitation OR resuscitation ti.ab.sh.] LIMIT to human and english language.
Outcome:
122 papers were found, of which 115 were irrelevant or of insufficient quality to include. No single studies directly address the 3 part question. The 7 closest studies are shown below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Factors determining survival after ruptured aortic aneurysm: the hospital, the surgeon, and the patient. Ouriel K, Geary K, Green RM, et al. 1990, USA | 243 patients operated on with ruptured AAA | Retrospective study | Death within 30 days of operation | Overall model (MLR) showed initial low SBP<70, COPD, CRF and a non-vascular surgeon to be independent predictors | Amount of pre-op fluid has not been analyzed as a separate factor Analysis mainly of pre-op, pre-morbid type of surgeon and hospital factors |
| Factors affecting survival of patients with ruptured abdominal aortic aneurysm in a West Virginia community. Aburahma AF, Woodruff BA, Lucente FC, et al. 1991, USA | 73 patients operated on with ruptured AAA | Retrospective study | Death within 30 days of operation | Overall model (MLR) showed type of rupture; intra vs retroperitoneal to be only independent predictor | Amount of pre-op fluid has not been analyzed as a separate factor Pre-op factors, syncope, HB, BP and total blood loss or transfusions only significant when type of rupture not adjusted for |
| Ruptured abdominal aortic aneurysm: the Harborview experience. Johansen K, Kohler TR, Nicholls SC, et al. 1991, USA | 186 patients with ruptured AAA | Retrospective study | Pre-op death or death within 30 days of op | Pre-op cardiac arrest, age>80, female gender. Pre-op SBP <90mmHg or HCT <25% and total peri-op transfusions >15 associated with death | No MLR performed Pre-op fluids not a separate factor |
| Ruptured abdominal aortic aneurysms: repair should not be denied. Gloviczki P, Pairolero PC, Mucha P Jr., et al. 1992, USA | 231 patients operated on with ruptured AAA | Retrospective study | Death within 30 days of operation | Overall model (MLR) showed high APACHE II, initial low H/crit, SBP<90 and COPD to be independent predictors | Amount of pre-op fluid has not been analyzed as a separate factor Analysis mainly of pre-op and pre-morbid factors |
| Haemodynamic management in ruptured abdominal aortic aneurysm. Brimacombe J, Berry A. 1994, Australia | Patients with ruptured AAA | Review article. 112 total articles, about 10 specifically related to fluid resus. | Peri-operative mortality | Found no PRCTs, only retrospective work | Thought balance of evidence in conscious patients favoured minimal fluid with early surgery |
| Predictors of death in nonruptured and ruptured abdominal aortic aneurysms. Chen JC, Hildebrand HD, Salvian AJ, et al. 1996, Canada | 478 patients undergoing abdominal aortic aneurysm (AAA) surgery. 157 ruptured | Retrospective study. Ruptures analyzed separately. | Pre-op death or death within 30 days of operation | Pre-op model (MLR) showed age, conscious level and cardiac arrest to be independent predictors | Amount of pre-op fluid does not seem to have been analyzed as a separate factor |
| Effect of the duration of symptoms, transport time, and length of emergency room stay on morbidity and mortality in patients with ruptured abdominal aortic aneurysms. Farooq MM, Freischlag JA, Seabrook GR, et al. 1996, USA | 122 patients with ruptured AAA | Retrospective study | Total mortality and complications | Death associated with hypotension, short pre-surgical times and total transfusion required | No MLR performed Pre-op fluids not a separate factor |
Author Commentary:
No study appears to have addressed this specific question by valid statistical analysis. Current practice is clearly opinion based and at least a decent retrospective review is indicated.
Bottom Line:
Further research needs to be conducted into this area.
References:
- Ouriel K, Geary K, Green RM, et al.. Factors determining survival after ruptured aortic aneurysm: the hospital, the surgeon, and the patient.
- Aburahma AF, Woodruff BA, Lucente FC, et al.. Factors affecting survival of patients with ruptured abdominal aortic aneurysm in a West Virginia community.
- Johansen K, Kohler TR, Nicholls SC, et al.. Ruptured abdominal aortic aneurysm: the Harborview experience.
- Gloviczki P, Pairolero PC, Mucha P Jr., et al.. Ruptured abdominal aortic aneurysms: repair should not be denied.
- Brimacombe J, Berry A.. Haemodynamic management in ruptured abdominal aortic aneurysm.
- Chen JC, Hildebrand HD, Salvian AJ, et al.. Predictors of death in nonruptured and ruptured abdominal aortic aneurysms.
- Farooq MM, Freischlag JA, Seabrook GR, et al.. Effect of the duration of symptoms, transport time, and length of emergency room stay on morbidity and mortality in patients with ruptured abdominal aortic aneurysms.