volume replacment follwing hemorhage control

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Oded,

The whole conceptual framework for permissive hypotension is preoperative.
It does not apply postoperatively, since you must assume that the patient no
longer has uncontrolled hemorrhage: returning the blood pressure to normal
should no longer functionally imperil circulating volume.  If it does, you
have to look hard at that first operation.

When the patient remains hypoperfused after his major bleeding is controlled
(quite often the case), you must consider the remaining reasonable causes.
The culprit is typically enduring hypovolemia, which may be treated
aggressively and conventionally (i.e., crystalloids) in faith that the tank
no longer has gaping holes in it.  

But there are a stunning array of other conditions and complications which
may confound control, explaining why this phase is the purview and
responsibility of surgical critical care specialists at the trauma center.
If it takes more than a liter or two of crystalloids, effective management
may involve relocation.  You mustn't monkey with large volumes of blood or
colloids or (eek!) pressors unless you have the proper facilities and
experience to monitor and interpret the central responses.  This is no
longer ATLS territory; you're venturing deeply into the critical care
boards.

Pret Bjorn, RN, etc.
Eastern Maine Medical Center Trauma Program
Bangor, ME USA

-----Original Message-----
From: oded private [mailto:tangentcarrot at hotmail.com] 
Sent: Saturday, October 29, 2005 10:45 AM
To: trauma-list at trauma.org
Subject: Re: volume replacment follwing hemorhage control


"Permissiove hypotension is for the patient with non-compressible bleeding"-

well, that's preety clear,but I was intrested to hear about the approach to 
post operative fluid treatment from the same people practice "permissive 
hypotension", since they do have a diffrent theoretical (as I see it) 
approach to the whole concept of fluid resusscitation and it's golas. So,  
"give what you have" sounds rather odd to me- if "what I have" is LR/NS 
you're risking in blood dilution and interstitial edema, if "what I have" is

colloids than it's just no good, and "if what I have" is packed RBC and 
other blood components, well we don't have too much of it so we don't just 
give it to everyone, don't we?

>From: Eitan Melamed <eitanme2000 at yahoo.com>
>Reply-To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
>To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
>Subject: Re: volume replacment follwing hemorhage control
>Date: Fri, 28 Oct 2005 17:47:54 -0700 (PDT)
>
>Oded,
>
>Permissive hypotension is for the patient with non-compressible bleeding, 
>before surgical control. For controlled hemorrhage, give what you have, 
>based on perfusion status. I think that fluid choice a minor issue in this 
>case. The standard in most places is still crystalloids (LR, NS). If the 
>patient continues to be tachycardic but well perfused- don't give fluids. 
>He might suffer pain and benefit from IV morphine.
>Please read the special suppliment to J Trauma, June 2003.   The ENTIRE  
>journal is on this subject
>
>Eitan Melamed
>
>oded private <tangentcarrot at hotmail.com> wrote:
>Hello trauma list
>
>This question is for those of you who practice permissive
>hypotension/hypotensive resusscitation.
>What do you consider to be the standart for fluid and blood product
>adminstration after hemorhage is under control given-
>1. the patient is hypotensive (SBP<100, let's say, and maybe coauglophatic)
>2. the patient is normotensive but continues to be tachycardic
>
>Oded, Army Medic and much more
>IDF School of Military Medicine
>
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