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Fri Apr 13 17:48:38 BST 2007

Claudia,

Prof Mattox is right about some of my colleagues. However, we are  
educating them!

If you want references, there is a supplement to the Journal of Trauma  
from 2003 which is basically a series of reviews regarding fluid  
resus. Particularly worth a read is Tisherman's review about the  
future of fluid resus. As to the anaesthetic techniques to use, you  
will find almost nothing in the literature as anaesthetists have just  
got on with it. However, here is a practical guide for abdominal trauma:

Get the patient to theatre. No the orthopods can not do a "quick" MUA  
first, or any other such rubbish. The patient needs an operation NOW!

While this is happening site preferably two large bore intravenous  
cannulae, and take the bloods. In reality only a cross match is  
needed, but it seems impossible to prevent the rest. If you anticipate  
going over 6 units of red cells you should order 1:1:1 cells,ffp, and  
platelets. Attach drips to your lines and turn them off. You can argue  
for capping, flushing, and setting up drips in theatre. However, it is  
usually more practical to go with the former option.

In theatre get the patient positioned (usually supine), the monitors  
on, and lines sorted. Use the time to pre-oxygenate the patient as  
well. You have until the surgeon has scrubbed, and the nurses got the  
instruments ready. As soon as the surgeon is ready to prep (about two  
minutes if he/she is slow) perform a rapid sequence induction  
intubation using the drugs you are happy using (I err on the side of  
etomidate and suxamethonium). Maintain with a combination of sleep  
agent of choice (I favour isoflurane in oxygen, and avoid nitrous  
oxide), further neuromuscular blockade (I favour the nearest  
aminosteriod), and an opiate of your choice (I favour fentanyl).

The surgeon will prep and drape as quickly as possible and open the  
belly. Despite the fact that you are looking at something red that  
appears to be emulating Niagara Falls, do not give much in the way of  
fluid. Instead use the time to insert fluid warmers into your drips.  
If you have managed to get a warming blanket onto the patient as well,  
so much the better. Now you can plug it in and switch it on. If you  
have plenty of help, use it. Someone can write the chart for you,  
someone can check the blood, and someone can set up something like a  
fentanyl or vecuronium infusion for you. Noticed what is happening?  
Everybody is distracted and not fiddling (particularly with the drips,  
and, anyway, anaesthesia by committee is a disaster), and allowing you  
to get on with your task of giving the anaesthetic. I liken giving  
anaesthetics to walking across the abyss using a plank. Too far either  
way and your patient faces disaster. All that pre-op work up is about  
widening the plank. In this case someone has shaved it down so that  
you appear to be using a piece of string for the task. Concentrate on  
getting the balance. Enough fluid to keep vital organs alive, but not  
enough to increase the bleeding. If you manage to do the latter by  
overzealous fluids or drugs, the patient's red cell mass will rapidly  
be transfered to the surgical sucker. Generally a systolic BP in the  
70-80 mmHg range for a young fit adult is about right. This is very  
much a surrogate, and subject to all sorts of provisos, but is the  
best you have got. A 85 year old hypertensive is probably going to  
need it a bit higher, and an 18 year old athlete will tolerate it  
lower. Just use a little sense.

The only indication for vasopressors is a tiny dose to prevent the  
patient arresting because despite the maximum fluid flow possible the  
systolic is less than 45 mmHg and falling. This is called the Level 1  
criterion. It just gives you a few seconds to catch up (and the  
surgeon to get better control). I recommend no more than 0.5 mg  
meteraminol. Remember, it may take a minute or so to work.

As to ionotropes: TUTIT (Twits Use Tropes In Trauma).

At this point the surgeon will have some sort of haemorrhage control.  
Sometimes this is by the "5 quarrent pack" method, but others are  
used, depending on the situation. Some anaesthetists and surgeons like  
a slight rise in the pressure here (say 90 mmHg systolic), so that the  
bleeding can be seen and dealt with (e.g. removing one of the 5  
packs). However, I caution against it if there is any hint of large  
vessel injury. For these purposes that is any vessel that needs to  
tied off rather than burnt. In any case, keep the pressure low but the  
patient alive. Keep the warmers going as best you can, as cold blood  
has a nasty habit of not clotting. Keep an eye on the operative field  
(your surgeon can see it even better, so needs to be listened to). If  
you are getting "red water" you need clotting products, and if every  
surface is oozing you need platelets as well.

At some point your surgeon will achieve definitive haemostasis. This  
is defined as the point at which you can no longer pop the clot. Key  
clues that this has occured are the surgeon telling you, and their  
closing the wound. You now move to the "ICU phase". You can start to  
fill the patient back up. You will know if you are doing this right  
because the base excess will rise towards zero. This is what they will  
do on the ICU, but there is no reason (unless the surgeon has said  
otherwise) not to start it now.

With a little luck you should be delivering an improving patient to  
ICU some 90 minutes after induction of anaesthesia.

Now, the above is just a primer in one body cavity. There are many  
more issues to address because there are many more factors. However,  
the principles are easy:

Don't wait. Get on with it.

Keep the pressure down until it is safe to raise it.

Treat the patient's problem, not the chart.

Hope this helps.

Guy Jackson
London, UK

Quoting Claudia Baptista <claudiabaptista at hotmail.com>:

>
>
> Hello everybody!    I´m working at a presentation about Damage   
> Control Surgery.  I´m a Anesthesiology resident, so i´d like to get   
> some information about specific aspects of the intra-operative   
> period. I found a lot of papers about the surgery, but only one   
> about the anesthesia (Of course, I have thousand about the lethal   
> triade!).    Could you advise me some of the latest articles?      
> Thank You!!
>
> -------------------------
> MSN Busca: fácil, rápido, direto ao ponto.  Encontre o que você   
> quiser. Clique aqui.[1] Links:
> ------
> [1] http://g.msn.com/8HMABR/2734??PS=47575

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