permissive hypotension

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Although animal models show the benefits of permissive hypotension in 
controlling hemorrhage, there has not been any clear evidence in human 
trials showing either benefit or harm associated with permissive 
hypotension.

The recent effort of Dr. Dutton and his colleagues with the publication of 
“Hypotensive Resuscitation during Active Hemorrhage:  Impact on In-Hospital 
Mortality ,” should be lauded for it’s ambition.  However, as recognized by 
the article's authors, there were a number of issues that negatively 
affected the validity of this study.  The methods the authors proposed for 
the study (allowing the “hypotensive” group a blood pressure of 70 – 80 mm 
Hg) were technically never achieved.  The study sample was too small for 
adequate randomization – leading to differences in the two treatment groups 
in terms of the types of injuries they sustained.  And the proposed endpoint 
of in hospital mortality was perhaps too broad to detect subtle differences 
in treatments.

To date, the most reliable information we have concerning the benefits of 
deliberate hypotensive resuscitation lies in animal models.  The few 
clinical trials that address this subject do not provide sufficient credible 
information to make practice-changing decisions.  It is unwise to make 
assumptions based solely on these clinical trials and “bottom lines” printed 
in various trauma websites.

If anything, Dr. Dutton’s recent study shows the difficulty in carrying out 
a large prospective trial to study the effects of permissive hypotension in 
trauma victims.  To have any real benefit, the next study, if there is one, 
would most likely have to be a multi-centered trial, and explore differences 
in not only hemorrhaging trauma victims, but differences between varying 
injuries as well.  Until then, our best source of information remains to be 
our own experience along with a few well-designed animal models.


Steven Moore
Department of Emergency Medicine
Metropolitan Hospital
New York, NY






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