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Mon Aug 6 01:56:32 BST 2007

Thanks everyone for the replies to my earlier questions on theraputically reduced SBP.

  Prior to signing up for this list I raised the question about using pressors in trauma and to say I was met with resistence would be a kind understatement. But here is my madness.

  Pressors are used all the time in trauma, but nobody realizes it. How often in the OR or while sutering is epi used to constrict vasculature to help control bleeding? It seems to me, all the time. I would stipulate that cutting or suturing causes trauma. Maybe a controlled trauma or over a small area. But still a pressor used for bleeding control. (not to raise CVP)

  Now it was brought up on this list to use vasopressin. Stepping away from the TBI for a second, from cardiogenic shock of nontraumatic origin to spinal trauma, pressors are indicated; If not to aid in perfusion, then for what? I understand the dogma of no pressors comes from the idea that the pressor does not help CVP and therefore is contraindicated because the increase in BP gives a false impression of tissue perfusion. But from a common sense point of view, back to TBI, you are not trying to raise CVP, you are trying to raise MAP. So why would the pressor not work? Unfortunatly I don't know the answers to the following questions. Please can anyone tell me: 

  Which pressor? Why vasopresson over levofed or any other? Obviously some work differently than others, but I do not know why the focus is on Vasopressin.

  What doses are being considered and why? It seems to me using 40 units of vasopressin might be too much on a pt with a pulse, but what is the reasoning for the dose being used or is it titrated to effect?  

  The other side of the coin is by raising MAP with a pressor do you impact CVP? Are any other organs or systems negatively impacted? i.e. the kidneys?

  Does this idea simply come from the idea that in a cold, diaphoretic patient we might look at the BP reading and forget we treat patients not monitors?

  Thanks for taking time to consider this.

  Mike

KMATTOX at aol.com wrote:

In a message dated 8/5/2007 4:30:51 P.M. Central Daylight Time, ih7 at msn.com 
writes:

if the ICP is increased, you need to keep the MAP 60 mm higher so the blood 
flows forward through the brain

I would agree with that, but would plead that it is NOT crystalloid fluids 
which should be used to achieve that MAP. Remember that most of the studies 
of the past 30-40 yrs were in patients that had 3 liters (or more) challenge 
of crystalloid prior to any surgeon, especially neurosurgeon, seeing them. 
The ICP increase is a complex compartment syndrome and much of our 
traditional urban legend therapy actually iatrogenicly contributed to the spiraling 
increase in ICP. 

I am delighted to see the direction of the discussions on this web site, and 
do believe that it is going to lead to a whole new wave of research. 

k

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