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Fri Jan 30 02:06:31 GMT 2009

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,
>
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>
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Intra-operative Permissive Hypotension