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| Name | Class |
|---|---|
| Fondazione Policlinico Universitario Agostino Gemelli IRCCS | OTHER |
| Azienda Ospedaliero, Universitaria Pisana | OTHER |
| Hospital ClÃnico Universitario de Valencia | OTHER |
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The LIMIT-TBI trial is a multicenter, international, randomized, phase II clinical trial designed to evaluate the feasibility and safety of targeting a neutral fluid balance compared to standard care in critically ill adult patients with traumatic brain injury (TBI).
Fluid therapy is a cornerstone of TBI management, but optimal fluid balance remains uncertain, with both fluid overload and restriction potentially leading to adverse outcomes. This study aims to determine whether maintaining a daily fluid balance close to zero (±500 mL) during the first 5 days of ICU admission is achievable and safe.
Participants will be randomized within 48 hours of ICU admission to either a protocolized neutral fluid balance strategy or standard care. Outcomes include feasibility of achieving the target balance, organ complications, hemodynamic parameters, ICU resource utilization, and mortality and neurological outcomes up to 6 months.
Severe traumatic brain injury (TBI) is a major cause of mortality and long-term disability worldwide and frequently requires intensive care management. In these patients, preventing secondary brain injury is essential and involves optimizing cerebral perfusion pressure (CPP), systemic hemodynamics, and organ function. Fluid therapy plays a central role in achieving these goals.
However, the optimal fluid management strategy in TBI remains unclear. Excessive fluid administration may lead to complications such as pulmonary edema and worsening cerebral edema, while restrictive strategies may increase the risk of hypovolemia and impaired cerebral perfusion. Current guidelines provide limited or no specific recommendations due to the lack of high-quality randomized evidence. Observational data suggest that a more positive fluid balance is associated with worse outcomes, but causality has not been established.
The LIMIT-TBI trial is a pragmatic, international, multicenter, randomized, unblinded, parallel-group phase II study designed to address this evidence gap. Adult patients with TBI admitted to the ICU will be randomized within 48 hours in a 1:1 ratio to either:
A neutral fluid balance strategy, targeting a daily balance of 0 mL (±500 mL) and cumulative neutrality over the first 5 days, using a protocolized approach combining fluid restriction, vasopressors, and diuretics when needed; A standard of care strategy, in which fluid administration is guided by local practice and clinician judgment.
In the intervention group, all fluid inputs (intravenous fluids, medications, and enteral nutrition) and outputs are strictly monitored. Maintenance fluids are minimized, and adjustments are made daily to achieve neutrality while maintaining adequate mean arterial pressure and cerebral perfusion pressure targets.
The primary objective is to assess the feasibility and safety of achieving a neutral fluid balance, defined as maintaining a daily balance within ±500 mL. Secondary outcomes include systemic complications, hemodynamic parameters (including CPP), fluid administration metrics, vasopressor and diuretic use, organ support-free days, and ICU/hospital mortality. Long-term outcomes include 6-month mortality and neurological status assessed using the Glasgow Outcome Scale Extended (GOSE).
A total of 88 patients will be enrolled to provide adequate power to detect differences in fluid balance between groups. Statistical analyses will include linear mixed models for repeated measures and appropriate comparative tests for secondary outcomes, with multiple imputation for missing primary endpoint data.
This trial will provide important preliminary randomized evidence on fluid management in TBI and inform the design of future large-scale trials aimed at improving outcomes in this high-risk population.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Neutral Fluid Balance Strategy | Experimental | Participants randomized to the experimental arm will receive a protocolized fluid management strategy targeting a neutral fluid balance (0 ± 500 mL per day) during the first 5 days following ICU admission. All fluid inputs (intravenous fluids, medications, enteral nutrition) and outputs (urine, drains, gastrointestinal losses, etc.) will be strictly monitored and included in the daily balance calculation. Fluid administration will be minimized, and no routine maintenance fluids will be administered unless required to ensure a minimum daily intake of approximately 1 L (including medications and nutrition). If the daily fluid balance exceeds ±500 mL, adjustments will be made in subsequent days by reducing fluid administration and/or introducing diuretics to achieve cumulative neutrality. Hemodynamic targets (mean arterial pressure ≥70 mmHg, systolic arterial pressure ≥100 mmHg, and/or cerebral perfusion pressure ≥60 mmHg) will be maintained using vasopressors (e.g., norepinephrine) |
|
| Standard of Care Fluid Management | No Intervention | Participants randomized to the control arm will receive standard fluid management according to local ICU practice and clinician judgment. Intravenous fluids may be administered as maintenance therapy if part of local protocols, and to correct hypovolemia, dehydration, electrolyte imbalances, or ongoing losses. Hemodynamic targets, including cerebral perfusion pressure, will be achieved using fluids and/or vasopressors at the discretion of the treating clinician, without a predefined protocol for fluid balance. Fluid balance will be monitored but no specific target for neutrality will be enforced. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Neutral Fluid Balance Strategy | Other | Protocolized strategy targeting a daily fluid balance of 0 ± 500 mL for 5 days using restricted fluids, diuretics, and vasopressors to maintain hemodynamic and cerebral perfusion targets. |
| Measure | Description | Time Frame |
|---|---|---|
| Feasibility of achieving a neutral daily fluid balance | Proportion of patients achieving a mean daily fluid balance within 0 ± 500 mL during the 5 days after ICU admission - mean daily fluid balance will be measured at day 5 as the mean of the fluid balances of the 5 previous days | At 5 days after randomisation |
| Measure | Description | Time Frame |
|---|---|---|
| Incidence of systemic organ complications | Incidence of new organ dysfunction or complications during ICU stay. | ICU discharge |
| Cerebral perfusion pressure (CPP) | Mean and daily cerebral perfusion pressure during ICU stay. |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Fabio Silvio Taccone, MD, PhD | Contact | +32 2 555 33 95 | fabio.taccone@hubruxelles.be |
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Erasme University Hospital | Recruiting | Brussels | 1070 | Belgium |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 34302787 | Background | Wiegers EJA, Lingsma HF, Huijben JA, Cooper DJ, Citerio G, Frisvold S, Helbok R, Maas AIR, Menon DK, Moore EM, Stocchetti N, Dippel DW, Steyerberg EW, van der Jagt M; CENTER-TBI; OzENTER-TBI Collaboration Groups. Fluid balance and outcome in critically ill patients with traumatic brain injury (CENTER-TBI and OzENTER-TBI): a prospective, multicentre, comparative effectiveness study. Lancet Neurol. 2021 Aug;20(8):627-638. doi: 10.1016/S1474-4422(21)00162-9. | |
| 29500701 |
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| All India Institute of Medical Sciences |
| OTHER |
| Erasmus University Rotterdam | OTHER |
| IRCCS Azienda Ospedaliera Universitaria San Martino - IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy | OTHER |
Restrictive Fluid Management Strategy (INTERVENTION) vs. Routine Fluid Management Strategy (CONTROL)
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| From randomisation to day 5 after randomisation |
| Daily fluid balance and fluid input | Mean daily fluid balance and total fluid input during the first 5 days | From randomisation to day 5 after randomisation |
| Vasopressor and diuretic use | Total and daily dose of vasopressors and diuretics during ICU stay. | ICU discharge |
| Vasopressor-free days | Number of days alive and free from vasopressor support. | From randomisation to day 28 after randomisation |
| Ventilator-free days | Number of days alive and free from invasive mechanical ventilation. | From randomisation to day 28 after randomisation |
| Therapy intensity level (TIL) | Maximum therapy intensity level during the intervention period. | At day 5 after randomisation |
| ICU and hospital mortality | All-cause mortality during ICU and hospital stay. | Hospital discharge |
| Neurological outcome (GOSE) | Functional neurological outcome assessed by Glasgow Outcome Scale Extended. | Hospital discharge |
| Long-term mortality | All-cause mortality at follow-up. | 180 days after randomization |
| Long-term neurological outcome (GOSE) | Functional neurological outcome assessed by Glasgow Outcome Scale Extended. Scale 1 to 8, 1= dead; 8=good recovery no social and mental deficits | 180 days after randomization |
| IRCCS Ospedale Policlinico San Martino | Recruiting | Genova | 16132 | Italy |
|
| Fondazione Policlinico Universitario Agostino Gemelli IRCCS | Recruiting | Roma | 00168 | Italy |
|
| Background |
| Oddo M, Poole D, Helbok R, Meyfroidt G, Stocchetti N, Bouzat P, Cecconi M, Geeraerts T, Martin-Loeches I, Quintard H, Taccone FS, Geocadin RG, Hemphill C, Ichai C, Menon D, Payen JF, Perner A, Smith M, Suarez J, Videtta W, Zanier ER, Citerio G. Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations. Intensive Care Med. 2018 Apr;44(4):449-463. doi: 10.1007/s00134-018-5086-z. Epub 2018 Mar 2. |
| 27654000 | Background | Carney N, Totten AM, O'Reilly C, Ullman JS, Hawryluk GW, Bell MJ, Bratton SL, Chesnut R, Harris OA, Kissoon N, Rubiano AM, Shutter L, Tasker RC, Vavilala MS, Wilberger J, Wright DW, Ghajar J. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017 Jan 1;80(1):6-15. doi: 10.1227/NEU.0000000000001432. |
| 36329266 | Background | Messina A, Bakker J, Chew M, De Backer D, Hamzaoui O, Hernandez G, Myatra SN, Monnet X, Ostermann M, Pinsky M, Teboul JL, Cecconi M. Pathophysiology of fluid administration in critically ill patients. Intensive Care Med Exp. 2022 Nov 4;10(1):46. doi: 10.1186/s40635-022-00473-4. |
| 11940738 | Background | Clifton GL, Miller ER, Choi SC, Levin HS. Fluid thresholds and outcome from severe brain injury. Crit Care Med. 2002 Apr;30(4):739-45. doi: 10.1097/00003246-200204000-00003. |
| 29253420 | Result | Majdan M, Plancikova D, Brazinova A, Rusnak M, Nieboer D, Feigin V, Maas A. Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. Lancet Public Health. 2016 Dec;1(2):e76-e83. doi: 10.1016/S2468-2667(16)30017-2. Epub 2016 Nov 29. |
| ID | Term |
|---|---|
| D000070642 | Brain Injuries, Traumatic |
| D001930 | Brain Injuries |
| ID | Term |
|---|---|
| D001927 | Brain Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
| D006259 | Craniocerebral Trauma |
| D020196 | Trauma, Nervous System |
| D014947 | Wounds and Injuries |
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