Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 90 Emergency (2014); 2 (2): 90-95 ORIGINAL RESEARCH Effects of Intravenous Fluid Therapy on Clinical and Biochemical Parameters of Trauma Patients Shahram Paydar1*, Hamid Bazrafkan1, Nasim Golestani2, Jamshid Roozbeh3, Abbas Akrami1, Ali Mohammad Moradi1 1. Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran 2. Emergency Medicine Department, Isfahan University of Medical Sciences, Isfahan, Iran 3. Nephrology ward, Department of Internal Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Abstract Introduction: The administration of crystalloid fluids is considered as the first line treatment in management of trauma patients. Infusion of intravenous fluids leads to various changes in hemodynamic, metabolic and coagula- tion profiles of these patients. The present study attempted to survey some of these changes in patients with mild severity trauma following normal saline infusion. Methods: This study comprised 84 trauma patients with injury of mild severity in Shahid Rajaei Hospital, Shiraz, Iran, during 2010-2011. The coagulation and metabolic values of each patient were measured before and one and six hours after infusion of one liter normal saline. Then, the values of mentioned parameters on one and six hours after infusion were compared with baseline measures using repeated measures analysis of variance. Results: Eighty four patients included in the present study (76% male). Hemoglobin (Hb) (df: 2; F=32.7; p<0.001), hematocrit (Hct) (df: 2; F=30.7; p<0.001), white blood cells (WBC) (df: 2; F=10.6; p<0.001), and platelet count (df: 2; F=4.5; p=0.01) showed the decreasing pattern following infusion of one liter of normal saline. Coagulation markers were not affected during the time of study (p>0.05). The values of blood urea nitrogen (BUN) showed statistically significant decreasing pattern (df: 2; F=5.6; p=0.007). Pressure of carbon dioxide (PCO2) (df: 2; F=6.4; p=0.002), bicarbonate (HCO3) (df: 2; F=7.0; p=0.001), and base excess (BE) (df: 2; F=3.3; p=0.04) values showed a significant deteriorating changes following hydration therapy. Conclusion: It seems that, the infusion of one liter normal saline during one hour will cause a statistically significant decrease in Hb, Hct, WBC, platelet, BUN, BE, HCO3, and PCO2 in trauma patients with mild severity of injury and stable condition. The changes in, coagulation profiles, pH, PvO2, and electrolytes were not statistically remarkable. Key words: Fluid Therapy; blood gas analysis; hemodilution; multiple trauma Cite This Article as: Paydar S, Bazrafkan H, Golestani N, Roozbeh J, Akrami A, Moradi AM. Effects of intravenous fluid therapy on clinical and biochemical parameters of trauma patients. Emergency. 2014;2(2):90-5. Introduction:1 rauma injury is one of the most important chal- lenges confronting the field of medicine world- wide. Annually, almost five millions people die from injuries (1). Trauma, besides cancer and cardiac diseases are the leading causes of premature deaths in people before 65 years of age in many countries (2). Uncontrolled bleeding, followed by hemorrhagic shock and coagulation abnormalities, is the main cause of preventable death in these patients (3, 4). Fluid therapy is the cornerstone of treatment in such situation. The proper protocol of hydration therapy for trauma pa- tients, has not yet been prepared. On the other hand, monitoring the hemodynamic and metabolic changes during resuscitation process is crucial (5-7). The effects *Corresponding Author: Shahram Paydar, MD. Trauma Research Center, Shahid Rajaei Trauma Hospital, Shahid Chamran blvd, Shiraz, Iran. Tel/Fax: +987116254206. Email: paydarsh@sums.ac.ir Received: 3 May 2014; Accepted: 3 June 2014 of fluid therapy on hemodynamic and metabolic profile of the trauma patients are not completely clear. Only, there are few studies in this field which all are almost based on elective surgery patients, self-experiences, and experts' opinions (8-11). It seems that, the in- creased intravascular volume could have various effects on clinical and para-clinical aspects of patients. The in- creasing circulating volume leads to mounting the car- diac output by a heightened preload. The subsequent elevated cardiac output causes some changes in pa- tient`s clinical findings such as blood pressure, heart rate, urine output, and skin temperature (12). There are several laboratory markers which are representative of tissue perfusion and metabolic changes during resusci- tation (13, 14). These indices include base excess, se- rum lactate, tissue pH, and blood urea nitrogen (BUN) (14-16).The results of previous studies on effects of fluid therapy revealed various findings which could be due to the different situations, the severity of injury and T This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 91 Paydar et al initial hemodynamic and metabolic status of patients. To determine these effects, the present study was aimed to assess the changes in biochemical markers of trauma patients after infusion of one liter normal saline. Methods: The present study was conducted in trauma center of Shahid Rajaei hospital, Shiraz, Iran, in 2010-2011. The study protocol was approved by Ethics Committee of Shiraz University of Medical Sciences. Written informed consent was obtained from all patients. The patients younger than 16 and older than 60 years old, pregnant women, diabetic patients, those receiving blood trans- fusion, patients suffered from hepatic or cardiac failure, and subjects with coagulation abnormalities were ex- cluded from the study. The severity of injury in all in- cluded patients was mild (score=4) based on revised trauma score (RTS). At the time of arrival to the emer- gency department, all the patients were visited and carefully examined by a general surgery resident. The metabolic and coagulation markers included complete blood count (CBC), BUN, Sodium (Na), Potassium (K), venous blood gas (VBG), international normalized ratio (INR), prothrombin time (PT), and partial thromboplas- tin time (PTT) were checked and entered to designed data form. Clinical values such as heart rate, blood pres- sure and respiratory rate were also measured and cal- culated. Then, one litter normal saline was infused to patients within one hour and the mentioned markers rechecked after one and six hours from admission time. All blood samples were derivate from the opposite site of punctured upper extremity. Data were analyzed using the SPSS statistical software version 18.0. Quantitative data were expressed as mean ± standard deviation and qualitative ones as frequency and percentage. Repeated measures analysis of vari- ances (ANOVA) was used to compare the clinical and biochemical values of patients at one and six hours after fluid therapy with base line. P value < 0.05 was consid- ered significant. Results: Of 84 patients who included in the present study, 64 (76%) were male. The mean age of patients was 32.1± 4.5 years. The types of injury were 54 (64.2%) long bones fracture, 9 (10.7%) head trauma, 4 (4.8%) chest trauma, and 17(20.2%) multiple trauma. The means of patients' systolic blood pressure, pulse rate, and respir- atory rate on admission were 120.2±17.0 mmHg, 82.5±9.2/minute and 18.3±1.1/minute, respectively. Table 1 compares vital signs of patients among the time of admission, one hour, and six hours after infusion. Table 2 and figure 1 show the comparison of Table 1: The comparison of vital signs on arrival time with those in one and six hours after infusion of one-liter normal saline (mean±SD)  Vital signs Admission 1 hour 6 hours P SBP (mmHg) 120.2±17.0 120.9±12.8 120.0±11.0 0.91 RR/minute 18.3±1.1 18.9±2.3 18.7±2.3 0.42 PR/minute 82.5±9.2 81.2±7.8 84.2±9.5 0.74 SBP: systolic blood pressure; RR: respiratory rate; PR: pulse rate. Table 2: The comparison of coagulation and metabolic values (mean±SD) on arrival time with those in one and six hours after infusion of one-liter normal saline  Characters Admission 1 hour 6 hours P WBC/mm3 12869.5±5272.5 12739.1±5012.8 11104.7±3492.0 <0.001 Hb (mg/dl) 13.7±1.6 13.05±1.8 12.7±1.8 <0.001 Hct (%) 40.5±4.4 38.4±5.09 37.9±5.1 <0.001 Plt/mm3 211160±64812 197443±57081 197987±60765 0.01 PT (second) 13.04±1.8 13.6±1.8 12.9±1.6 0.21 PTT (second) 39.4±5.5 39.7±6.9 40.8±8.1 0.26 INR 1.15±0.2 1.15±0.2 1.15±0.2 0.67 BUN (mg/dl) 16.1±4.4 15.4±4.4 15.3±4.7 0.007 Na (meq/l) 141.7±3.8 141.2±4.1 140.6±4.7 0.048 K (meq/l) 4.0±0.5 4.0±0.4 4.1±0.5 0.32 WBC: White blood cell; Hb: hemoglobin; Hct: hematocrit; Plt: Platelet: PT: prothrombin time; PTT: partial thromboplastin time; INR: interna- tional normalized ratio; BUN: blood urea nitrogen; Na: Sodium; K: Potassium. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Emergency (2014); 2 (2): 90-95 92 coagulation and metabolic factors on arrival time with those in one and six hours after infusion of one-liter normal saline. Hemoglobin (Hb) (df: 2; F=32.7; p<0.001) and hematocrit (Hct) (df: 2; F=30.7; p<0.001) levels both decreased one (pHb<0.001; pHct<0.001) and six (pHb<0.001; pHct<0.001) hours after infusion. Platelet count decreased after one hour (p<0.01) and fixed in six hours (p<0.35) (df: 2; F=4.5; p=0.01). White blood cells (WBC) decreased during the both studied times (df: 2; F=10.6; p<0.001). Coagulation markers were not affect- ed during the time of study. The values of BUN showed statistically significant decreasing pattern following hydration therapy (df: 2; F=5.6; p=0.007). Table 3 and figure 2 shows the comparison of venous blood gas pa- rameters on arrival time with those in one and six hours after infusion. Pressure of carbon dioxide (PCO2) (df: 2; F=6.4; p=0.002), bicarbonate (HCO3) (df: 2; F=7.0; p=0.001), and base excess (BE) (df: 2; F=3.3; p=0.04) values showed a significant deteriorating changes following infusion. Discussion: According to the findings of present study, although different metabolic and coagulation markers showed various patterns of changes, there were statistically significant changes only in Hb, Hct, platelet, and BUN values of patients following infusion of one liter normal saline. Also among VBG parameters PCO2, HCO3, and BE showed significant deteriorating pattern following hy- dration therapy. Successful hydration therapy and fluid resuscitation is determined by maintenance of tissue perfusion. In this context, isotonic crystalloids usually are the first line fluid used in many trauma centers (17). On the other hand, crystalloids infusion leads to tissue edema, he- modilution and decreasing concentration of coagulative factors (18, 19). Despite positive effects of fluid infusion on vital signs, the reduction possible in oxygen-carrying capacity and consequently deteriorating tissue perfu- sion are undeniable side effects. In other word, the vital signs were maintained in patients by temporary in- crease in intravascular volume according to Frank Star- ling law, at the cost of decreasing oxygen-carrying ca- pacity. The study of Lahsaee et al. showed significant A B C D Figure 1: Pattern of cell blood counts including hemoglobin (A), hematocrit (B), white blood cells (C), and platelet (D) changes following infusion of one liter normal saline at the time of study. ** Significant difference from pre-treatment time at level p<0.001. * Significant difference from baseline at level p<0.01. # Significant difference from baseline at level p<0.05.  This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 93 Paydar et al decrease in Hb and Hct values following the hydration therapy in elective surgery patients (20). Crystalloid- induced hemodilution may be exacerbated with lower Hb in more severely-injured patients and unstable con- dition. Because of the importance of fluid therapy in management of trauma patients, removing it to conduct researches about the impact of fluid therapy on differ- ent indices is not ethical (19). But some studies con- ducted on animals, reported the effect of fluid therapy on indices such as blood pressure, lactate level, and Hct (19, 21). The effects of fluid therapy on BE and lactate have been studied in several investigations with differ- ent results (12, 14). Based on the finding of the present study, WBC count decreased one and six hour after Table 3: The comparison of venous blood gas parameters (VBG) on arrival time with those in one and six hours after infusion of one liter normal saline (mean±SD)  parameters Base line 1 hour 6 hours P PVO2 (mmHg) 42.6±26.45 45.5±19.1 45.3±19.8 0.38 PCO2 (mmHg) 36.1±7.6 36.2±7.0 33.4±6.2 0.002 HCO3 (mmol/l) 22.5±3.6 22.2±3.9 21.2±3.6 0.001 BE (mEq/L) -1.4±3.2 -1.9±3.6 -2.3±3.5 0.04 pH 7.41±0.07 7.40±0.05 7.42±0.05 0.08 VBG: venous blood gas; PO2: venous pressure of oxygen; PCO2: venous pressure of carbon dioxide; HCO3: Bicarbonate; BE: base excess. A B C Figure 2: Pattern of venous blood gas parameters including bicarbonate (A), venous pressure of carbon dioxide (B), and base deficit (C) changes following infusion of one-liter normal saline at the time of study. ** Significant difference from baseline at level p<0.001. * Significant difference from baseline at level p<0.01. # Significant difference from pre-treatment time at level p<0.05.  This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2014 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Emergency (2014); 2 (2): 90-95 94 normal saline infusion, which also may be due to he- modilution. The platelet count showed similar decreas- ing pattern to the WBC. Coagulation profile did not ex- perienced any significant changes. This issue was against the findings of Chin LC et al., indicating the hy- po-coagulation state as one of the important adverse effects of fluid therapy (22). There are few studies re- porting sufficient amounts of VBG values in patients with injury of mild severity (23). In this study, the mean values of initial VBG were reported as near normal val- ues in mild severity-injured trauma patients. Acidosis is considered as one of the hydration side effects, in Gerecht study (16, 24). But in the present study the pH level did not change significantly. This could be due the mild injury of the patients and low volume of fluid infu- sion. The finding of the present study revealed a wors- ening pattern of BE, PCO2, and HCO3 following infusion of one liter normal saline. It seems that monitoring and assessment of the changes in these values are necessary in patients with more severe injuries. Many studies have shown a reduction in BUN level as a result of the increasing of urine output after normal saline infusion in trauma patients. As well, in this study the BUN showed statistically significant decreasing changes after infusion of fluid. Further studies including patients with more severe injury are required to evaluate the impact of fluid therapy on different clinical and para-clinical aspects of trauma patients. Although more studies are needed in this area, it seems that we should revise our concept in trauma patients' resuscitation. However, it should be done noticing to patients` individual condi- tions, injury severity, vital signs, and primary laborato- ry findings such as Hb, BE, lactic acid and etc. Conclusion: It seems that, the infusion of one liter normal saline during one hour will cause a statistically significant de- crease in Hb, Hct, WBC, platelet, BUN, BE, HCO3, and PCO2 in trauma patients with mild severity of injury and stable condition. 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