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Fri Jan 30 01:13:09 GMT 2009

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,

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Intra-operative Permissive Hypotension