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Sun Feb 1 21:34:10 GMT 2009

Thanks Matthew, very interesting - look forward to the paper.  (I think the
details of the anaesthesia's probably irrelevant.  I'd leave it out.)  Got a
projected completion date??Karim

2009/1/31 Carrick, Matthew M. <mcarrick at bcm.tmc.edu>

> Karim,
>
> The stopping point of intervention in the study is the end of the surgery.
>  We discussed stopping the study at the time of surgical control of blood
> loss.  After we made this decision we decided that we would record the "time
> of surgical control" so that if we needed to modify the protocol we could
> using good data.  It turns out that we usually do not have any idea when
> the control of blood loss time is.  Most of the data forms were filled out
> with a "?".  Looking at the data it looks like it to me that it really does
> not matter much.  Once the bleeding is stopped the patients tend to have
> blood pressures above the minimum MAP for their group (like you said they
> find their own BP).
>
> Resuscitation in liberalized on arrival to the ICU.  There is no protocol
> to bump  the MAP up at the end of the case to test for bleeding.  We decided
> that tracking 24 hour blood requirements, and take backs for bleeding would
> serve as a surrogate for the low MAP masking inadequate surgical control
> of bleeding.
>
> The actual MAP's are not that different for the two groups.  It could be as
> you think, that they find their own BP's as you say.  It also could be that
> the patient populations are not equal (the ISS is higher in the Normal MAP
> group) etc.
>
> The MAP's during the first 30 minutes are lower in the 50 group, and the
> time spent with a MAP<65 is longer in the 50 MAP group.
>
> Also there is a difference in the amount of blood given (lower in the 50
> group) and blood loss (lower in the 50 group).
>
> As for the anesthetic gas and meds:
>
> The only difference in the administration of IV meds is that fewer patients
> in the normal MAP group received fentanyl.  Patients that did get fentanyl
> got equal amounts.
>
> An equal number of patients received inhaled anesthetic agents and in
> similar amounts.  The MAC levels of the inhaled agents was similar.
> Isoflourane was the most common inhaled agent used and it was used at around
> 50% of MAC.  Desflourane and Sevoflourane were also used but less often.
>
> Dr. Dutton was the discussant at EAST and he had the same questions you
> did.  We made some slides with tables showing the anesthetic usage to answer
> his questions.  I will try and get them included in the JoT article.
>
> Sorry about not including head injured patients.  We did that in order to
> get buy-in from all of the people involved (anesthesia, IRB, surgeons)
>
> Jakob,
>
> I completely agree that permissive hypotension is a team effort, and if
> anything is harder for the anesthesiologists.
>
> They have to balance the MAP at the same time they try and figure out if
> the patient is normovolemic and vasodialated from their anesthetic agents or
> hypovolemic from blood loss.  They also have to keep an eye on artificial
> "drops" in blood pressure from the surgeon eviscerating the small bowel,
> removing aortic clamps, and lifting the heart...
>
> We wanted the trial to have one outcome only, and that is weather or not a
> lower targeted MAP would result in an improved survival.  To do that we had
> to keep the trial as simple as possible in terms of the measures the
> anesthesiologists used to reach their target.   A more specific protocol
> might
> lead to an interpretation of the methods we used to get the blood pressure
> and not a study of hypotensive resuscitation.
>
> I like the remifentanyl idea.
>
> Thanks for the positive feed back.
>
> Keep in mind that this is only the safety phase of the study and so almost
> nothing we analyze reaches statistical significance.  The only conclusion I
> would draw at this point is that hypotensive resuscitation to a target
> minimum MAP of 50mmHg appears safe.
>
>
>
> Matt
> ________________________________
>
> From: Karim Brohi [mailto:karimbrohi at gmail.com]
> Sent: Sat 1/31/2009 6:42 AM
> To: Trauma &amp, Critical Care mailing list
> Subject: Re: Intra-operative Permissive Hypotension and Intra-operative
> Permissive Hypotension - How do you
>
>
>
> MatthewWell done with the study and the abstract.  You've got a long way to
> go but of course the results you present are very encouraging.  Most
> importantly they show (as do other papers), that permission hypotension
> strategies in actively bleeding trauma patients are *at least as safe as*
> more liberal strategies.
>
> I have a few questions & comments, just for my interest:
>
> * What's the stopping point of the study? (ie. when do you decide to
> liberalise resuscitation?)
>
> * What was the actual MAP and SBP of participants in the two groups?
> My guess is that they were equivalent.  I'm asking this not because I
> believe it to be a sign of a poor study - as most naysayers do of pervious
> studies - but because I think patients who are actively bleeding find their
> own MAP, and no amount of fluids can change that beyond a transient rise in
> BP.  All you do is end up giving more fluids to the higher BP group - and
> we
> know that fluid for fluid's sake is bad.
>
> * I'm really sad you excluded patients with a concomitant head injury from
> the study.
>
> I'm looking forward to the final results of the study. I also think you'll
> have a fantastic dataset to look at other aspects of the phsyiological
> response of these patients to bleeding and resuscitation.
>
> Karim
>
> 2009/1/30 Carrick, Matthew M. <mcarrick at bcm.tmc.edu>
>
> > At EAST I presented the data from our first 45 patients that we were able
> > to randomize in our intra-operative hypotensive resuscitation study.
>  This
> > was the first stopping point in which we were going to evaluate the trial
> > for safety.  We too were concerned about the possible negative effects
> that
> > hypotension may end on end organs.  We chose to analyze our data for an
> > increase in stroke, renal failure, of MI at 45 patients.  We planned to
> stop
> > the study if there was an increase in these complications or deaths in
> one
> > of the groups.
> >
> > We are randomizing patients to two groups for intra-operative
> resuscitation
> > of hypotensive patients.  Half of the patients are randomized to a target
> > minimum mean arterial pressure (MAP) of 50mmHg.  This is the permissive
> > hypotension group.  The other group is the control group and these
> patients
> > are randomized to a target minimum MAP of 65 mmHg.  (This "standard"
> blood
> > pressure was chosen by a survey of members of EAST and AAST.  Up to this
> > point there was no standard.)
> >
> > The anesthesiologists do not lower the blood pressure but if it is low
> they
> > only bring it back up to the target minimum.
> >
> > To answer Juan's question, we are following the number of times that
> > patients need to be brought back to the OR for bleeding.  Thus far the
> > number of take backs are equal in the two groups.  We were worried that
> in
> > the 50 group you may artificially think you have control of bleeding when
> > you do not.
> > That is why we are following this as an outcome of interest (not the
> > primary end point)
> >
> > So far we are early in the trial.  We have the sample size calculated at
> > 271 patients.  The primary outcome will be Kaplan-Meier 30 day survival.
>  We
> > are actually at 90 patients now and will be having our second interim
> > analysis in the next couple of weeks.
> >
> > I have attached an extended abstract to this email. The abstract
> describes
> > the first 45 patients (safety phase) of the study.  The full paper has
> been
> > submitted to the Journal of Trauma.
> >
> >
> > Matt Carrick
> >
> > ________________________________
> >
> > From: Teperman, Sheldon [mailto:Sheldon.Teperman at nbhn.net]
> > Sent: Fri 1/30/2009 9:45 AM
> > To: 'trauma-list at trauma.org'
> > Subject: RE: trauma-list Digest, Vol 67, Issue 47-Permissive Hypotension
> >
> >
> >
> >
> >  I agree with Karim that permissive Hypotension is a temporary evil.
>  But,
> > by the same token after you  have done the "heroic suture" part of the
> > operation, A lot of Blood pressure is most certainly a bad thing. I think
> > its critical to keep the pt well sedated ( read asleep) with excellent
> > analgesia and a very slow emergence from Anesthesia. After a "Do" like
> the
> > one Juan is talking about, the pt needs to be well on the way to
> reversing
> > their base and other physiologic deficits, before you let your suture
> lines
> > face to much testing.
> >        We did a GSW to the SVC( Bullet actually sitting in the SVC-I have
> a
> > picture if anyone wants to see) here last week on a young woman. I came
> back
> > to the SICU about an hour after she got there to find her wide awake with
> a
> > BP of 180 systolic. I was not happy, thinking about our suture line.
> > We put her back down and let her emerge gradually.  She did fine...Shel
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org [mailto:
> > trauma-list-bounces at trauma.org] On Behalf Of
> > trauma-list-request at trauma.org
> > Sent: Friday, January 30, 2009 7:01 AM
> > To: trauma-list at trauma.org
> > Subject: trauma-list Digest, Vol 67, Issue 47
> >
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> >
> > Today's Topics:
> >
> >   1. Re: Lung Contusion (Karim Brohi)
> >   2. Re: Intra-operative Permissive Hypotension (Karim Brohi)
> >   3. TBI and beta blockers (Errington Thompson )
> >   4. Intra-operative Permissive Hypotension - How do you
> >      accomplish /      prefer...? (Jakob Stensballe)
> >
> >
> > ----------------------------------------------------------------------
> >
> > Message: 1
> > Date: Fri, 30 Jan 2009 01:59:43 +0000
> > From: Karim Brohi <karimbrohi at gmail.com>
> > Subject: Re: Lung Contusion
> > To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
> > Message-ID:
> >        <b8b351510901291759k7fef34f4r4a393c3fd6c888e2 at mail.gmail.com>
> > Content-Type: text/plain; charset=ISO-8859-1
> >
> > Nothing earth-shattering to my knowledge.  One of the most interesting
> > areas has always been how you ventilate a patient with severe unilateral
> > pulmonary contusions - ie. a very compliant normal lung and a very
> > non-compliant contused lung.  And how you protect the good lung from ARDS
> > induced by
> > bronchial blood etc.  I think we're pretty poor at managing this sort of
> > injury in general.K
> >
> > 2009/1/29 Jose Luis Danguilan <jdanguilan at gmail.com>
> >
> > > Dear Karim,
> > >
> > > Anything new in treating flail chest with pulmonary contusion?
> > > Mechanical ventilator (internal splinting), etc.?
> > >
> > > Thanks.
> > >
> > > Jose Luis J. Danguilan, MD
> > > Manila, Philippines
> > >
> > >
> > > On 1/29/09, Karim Brohi <karimbrohi at gmail.com> wrote:
> > > >
> > > > While I would agree with minimizing crystalloids and maintaining
> > > euvolaemia
> > > > I don't think there's any evidence to support fluid restriction in
> > > > these patients.  A normal enteral fluid requirement should be
> > > > adequate.  No diuretics.
> > > > Karim
> > > >
> > > >
> > > > On 01/29/2009, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
> > > > >
> > > > > You are correct.   Lasix is probably contraindicated in
> > > > > pulmonary  contusion.
> > > > >   We would use fluid RESTRICTION to even almost no  crystalloid
> > > > > fluid
> > > at
> > > > > all.    AVOID ALBUMIN at all  cost.    ONE doctor, not a team of
> > > multiple
> > > > > consultants writing  orders
> > > > >
> > > > > k
> > > > >
> > > > >
> > > > >
> > > > > In a message dated 1/28/2009 8:32:21 P.M. Central Standard Time,
> > > > > errington at erringtonthompson.com writes:
> > > > >
> > > > > As a  rule we don't use Lasix in pulmonary contusions.  The goal
> > > > > in caring  for patients with pulmonary contusions is euvolemia.
> > > > > Intubate  early if necessary. Head of the bed should be elevated.
> > > > > No  prophylactic antibiotics.  Early tracheostomy.
> > > > >
> > > > > Guys, am I missing  anything?
> > > > >
> > > > >
> > > > > **************From Wall Street to Main Street and everywhere in
> > > between,
> > > > > stay
> > > > > up-to-date with the latest news. (
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> http://aol.com/?ncid=emlcntaolcom00000023>  <
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> > > > > )
> > > > > --
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> >
> >
> > ------------------------------
> >
> > Message: 2
> > Date: Fri, 30 Jan 2009 02:06:31 +0000
> > From: Karim Brohi <karimbrohi at gmail.com>
> > Subject: Re: Intra-operative Permissive Hypotension
> > To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>
> > Message-ID:
> >        <b8b351510901291806n5d2e8ae1u732e66cbbbb3266b at mail.gmail.com>
> > Content-Type: text/plain; charset=ISO-8859-1
> >
> > Juan
> > We're seeing this more and more - not just with intra/post-op but also
> with
> > angio where only blood vessels seen to 'blush' are embolised, but of
> course
> > there's no extravasation when you're running a BP of 60 - and the rebleed
> in
> > ICU - in some studies up to 40% of cases.
> >
> > In my mind permissive hypotension persists until you've turned off the
> > bleeding.  Any longer is counter-productive.  Then there should be an
> > aggressive phase of resuscitation to restore perfusion.  If you do this
> on
> > the operating table you notice the internal mammaries / skin vessels etc
> > beginning
> > to bleed again and can do something about it.
> >
> > Permissive hypotension is a temporary necessary evil, not a goal.
> >
> > K
> >
> > 2009/1/30 Duchesne, Juan C <jduchesn at tulane.edu>
> >
> > > Looking forward for Carrick paper. He did a good job......good kid!
> > > Good to hear your kind words Ron. Sometimes disruption of homeostasis
> > > (Physiologic Karma) is not what the body is telling you to do in
> surgery.
> > > Sometimes we need to be observers rather than hammering the small nail
> > > with the big hammer :) Damage Control Resuscitation is a complex
> > > intervention not solely successful because of a close ratio hemostatic
> > > resuscitation (CRHR) but rather successful when CRHR is use in
> > > combination with low volume resuscitation, permissive hypotension and
> > > damage control surgery. The question should no longer be if permissive
> > > hypotension works but rather for how long we need to stay on it?
> > > Still a lot of work ahead!
> > > Cheers
> > > j
> > >
> > > Juan C. Duchesne MD, FACS, FCCP
> > > Director Surgical Hospital Center
> > > Director Tulane Surgical Intensive Care Unit AMR Regional Director
> > > Louisiana Emergency Response Network
> > >
> > >
> > > Division of Trauma and Critical Care Surgery Tulane & LSU Department
> > > of Surgery and Anesthesiology 1430 Tulane Ave., SL-22 New Orleans LA
> > > 70112-2699 Tel. 504-988-5111 Fax. 504-988-3683
> > >
> > >
> > >
> > >
> > >
> > > ________________________________
> > >
> > > From: trauma-list-bounces at trauma.org on behalf of Gross, Ronald
> > > Sent: Thu 1/29/2009 10:53 AM
> > > To: 'Trauma &amp; Critical Care mailing list'
> > > Subject: RE: Intra-operative Permissive Hypotension
> > >
> > >
> > >
> > > All I can say is WOW!  Well done, Juan.  Intentional or not, it is
> > > apparently the way to go - and just so I can honestly state my bias, I
> > > have had the same experience, both in the desert and here in N.E.!
> > >
> > > Ron
> > >
> > > -----Original Message-----
> > > From: trauma-list-bounces at trauma.org [mailto:
> > > trauma-list-bounces at trauma.org] On Behalf Of Duchesne, Juan C
> > > Sent: Thursday, January 29, 2009 11:21 AM
> > > To: Trauma &amp; Critical Care mailing list
> > > Subject: Intra-operative Permissive Hypotension
> > >
> > > List members:
> > >
> > > We had 3 cases of IVC injuries in one week here at Charity thanks to
> > > our nice and busy knife and gun club, of which one died. In one of the
> > > cases good hemostatic resuscitation was achieved but of interest the
> > > blood pressure on the a-line was kept to a systolic of 88 during
> > > surgery (completely not on purpose). After removing the right kidney
> > > and repairing the anterior IVC injury there was no signs of surgical
> > > bleeding. The aorta was intact. Abdomen was packed with minimal output
> > > from the wound vac. Coagulation parameters were effectively corrected
> > > in the OR. 4 hours after transferring the patient to the TICU and
> > > resolution of anesthesia his blood pressure went up to 140's and with
> > > this his wound vac started pouring out blood.........took him back to
> > > the OR and there was bleeding from all my suture lines which we
> > > re-enforced. Patient went for another look that same day with similar
> > > presentation. He received (53PRBC:53 Plasma: 30 platelets) with first
> > > 24 hrs intra-op crystalloid of 8 liters (3 surgeries). He was
> > > extubated day 2.
> > >
> > >
> > >
> > > I am curious to hear what Dr Mattox and the rest of the list members
> > > think about this? ...............
> > >
> > > Intra-operative permissive Hypotension?.......Fact or Poor surgical
> > > technique?
> > >
> > >
> > >
> > > In addition to the early and aggressive administration of blood
> > > products and plasma with limitation of crystalloids to aid in the
> > > resuscitation of severely injured trauma patients, permissive
> > > hypotension is an essential component of Damage Control Resuscitation
> > > a process that starts from the scene, into ED and into the OR. Once we
> > > start surgical correction of bleeding we forget about this process.
> > > Permissive hypotension involves keeping the blood pressure low enough
> > > to avoid exsanguination while maintaining perfusion of end organs. Is
> > > there a benefit to extend this process in the OR?
> > >
> > >
> > >
> > > Thanks
> > >
> > > J
> > >
> > >
> > >
> > > Juan C Duchesne M.D., FACS, FCCP
> > >
> > > Trauma and Critical Care Surgery Section
> > >
> > > Medical Director Surgical Hospital Center
> > >
> > > Medical Director Surgical Intensive Care Unit
> > >
> > > Louisiana ATLS / PHTLS State Faculty
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > > Tulane University School of Medicine
> > >
> > > 1430 Tulane Ave., SL-22
> > >
> > > New Orleans LA 70112-2699
> > >
> > > Tel. 504-988-5111
> > >
> > > Fax. 504-988-3683
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > >
> > > -----Original Message-----
> > > From: trauma-list-bounces at trauma.org
> > > [mailto:trauma-list-bounces at trauma.org] On Behalf Of Karim Brohi
> > > Sent: Thursday, January 29, 2009 9:35 AM
> > > To: Trauma &amp, Critical Care mailing list
> > > Subject: Re: Lung Contusion
> > >
> > >
> > >
> > > While I would agree with minimizing crystalloids and maintaining
> > > euvolaemia
> > >
> > > I don't think there's any evidence to support fluid restriction in
> > > these
> > >
> > > patients.  A normal enteral fluid requirement should be adequate.  No
> > >
> > > diuretics.
> > >
> > > Karim
> > >
> > >
> > >
> > >
> > >
> > > On 01/29/2009, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
> > >
> > > >
> > >
> > > > You are correct.   Lasix is probably contraindicated in
> > >
> > > > pulmonary  contusion.
> > >
> > > >   We would use fluid RESTRICTION to even almost no  crystalloid
> > > > fluid
> > > at
> > >
> > > > all.    AVOID ALBUMIN at all  cost.    ONE doctor, not a team of
> > > multiple
> > >
> > > > consultants writing  orders
> > >
> > > >
> > >
> > > > k
> > >
> > > >
> > >
> > > >
> > >
> > > >
> > >
> > > > In a message dated 1/28/2009 8:32:21 P.M. Central Standard Time,
> > >
> > > > errington at erringtonthompson.com writes:
> > >
> > > >
> > >
> > > > As a  rule we don't use Lasix in pulmonary contusions.  The goal in
> > >
> > > > caring  for patients with pulmonary contusions is
> > >
> > > > euvolemia.  Intubate  early
> > >
> > > > if necessary. Head of the bed should be elevated.  No  prophylactic
> > >
> > > > antibiotics.  Early tracheostomy.
> > >
> > > >
> > >
> > > > Guys, am I missing  anything?
> > >
> > > >
> > >
> > > >
> > >
> > > > **************From Wall Street to Main Street and everywhere in
> > > between,
> > >
> > > > stay
> > >
> > > > up-to-date with the latest news.
> > > (http://aol.com?ncid=emlcntaolcom00000023 <
> http://aol.com/?ncid=emlcntaolcom00000023>  <
> > http://aol.com/?ncid=emlcntaolcom00000023>  <
> > > http://aol.com/?ncid=emlcntaolcom00000023>
> > >
> > > > )
> > >
> > > > --
> > >
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> > >
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> >
> > ------------------------------
> >
> > Message: 3
> > Date: Thu, 29 Jan 2009 23:29:43 -0500
> > From: "Errington Thompson " <errington at erringtonthompson.com>
> > Subject: TBI and beta blockers
> > To: "'Trauma &amp; Critical Care mailing list'"
> >        <trauma-list at trauma.org>
> > Message-ID: <0F9F6D41D41A4F8FAC62034ED4D2006E at errivid>
> > Content-Type: text/plain;       charset="us-ascii"
> >
> > Not a word on Beta Blockers and head injury patients.  Curious.
> >
> > Errington C. Thompson, MD, FACS, FCCM
> > Trauma/Surgical Critical Care
> > Radio Talk Host - WPEK 880 AM
> > Author - Letter to America
> > Asheville, NC
> >
> > -----Original Message-----
> > From: trauma-list-bounces at trauma.org [mailto:
> > trauma-list-bounces at trauma.org]
> > On Behalf Of Karim Brohi
> > Sent: Thursday, January 29, 2009 9:00 PM
> > To: Trauma &amp, Critical Care mailing list
> > Subject: Re: Lung Contusion
> >
> > Nothing earth-shattering to my knowledge.  One of the most interesting
> > areas has always been how you ventilate a patient with severe unilateral
> > pulmonary contusions - ie. a very compliant normal lung and a very
> > non-compliant contused lung.  And how you protect the good lung from ARDS
> > induced by
> > bronchial blood etc.  I think we're pretty poor at managing this sort of
> > injury in general.K
> >
> > 2009/1/29 Jose Luis Danguilan <jdanguilan at gmail.com>
> >
> > > Dear Karim,
> > >
> > > Anything new in treating flail chest with pulmonary contusion?
> > > Mechanical ventilator (internal splinting), etc.?
> > >
> > > Thanks.
> > >
> > > Jose Luis J. Danguilan, MD
> > > Manila, Philippines
> > >
> > >
> > > On 1/29/09, Karim Brohi <karimbrohi at gmail.com> wrote:
> > > >
> > > > While I would agree with minimizing crystalloids and maintaining
> > > euvolaemia
> > > > I don't think there's any evidence to support fluid restriction in
> > > > these patients.  A normal enteral fluid requirement should be
> > > > adequate.  No diuretics.
> > > > Karim
> > > >
> > > >
> > > > On 01/29/2009, KMATTOX at aol.com <KMATTOX at aol.com> wrote:
> > > > >
> > > > > You are correct.   Lasix is probably contraindicated in
> > > > > pulmonary  contusion.
> > > > >   We would use fluid RESTRICTION to even almost no  crystalloid
> > > > > fluid
> > > at
> > > > > all.    AVOID ALBUMIN at all  cost.    ONE doctor, not a team of
> > > multiple
> > > > > consultants writing  orders
> > > > >
> > > > > k
> > > > >
> > > > >
> > > > >
> > > > > In a message dated 1/28/2009 8:32:21 P.M. Central Standard Time,
> > > > > errington at erringtonthompson.com writes:
> > > > >
> > > > > As a  rule we don't use Lasix in pulmonary contusions.  The goal
> > > > > in caring  for patients with pulmonary contusions is euvolemia.
> > > > > Intubate  early if necessary. Head of the bed should be elevated.
> > > > > No  prophylactic antibiotics.  Early tracheostomy.
> > > > >
> > > > > Guys, am I missing  anything?
> > > > >
> > > > >
> > > > > **************From Wall Street to Main Street and everywhere in
> > > between,
> > > > > stay
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> >
> > ------------------------------
> >
> > Message: 4
> > Date: Fri, 30 Jan 2009 10:00:41 +0100
> > From: Jakob Stensballe <jakob.stensballe at rh.regionh.dk>
> > Subject: Intra-operative Permissive Hypotension - How do you
> >        accomplish /    prefer...?
> > To: trauma-list at trauma.org
> > Message-ID:
> >        <OFCC45172E.96603EAF-ONC125754E.002EC9EA-C125754E.00318089 at rh.dk>
> > Content-Type: text/plain; charset="us-ascii"
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> > End of trauma-list Digest, Vol 67, Issue 47
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