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Fri Jan 30 15:34:15 GMT 2009

Norm- That certainly is one of the drawbacks of OR permissive hypotension as I experienced in my case. A potential different course of action would of be to raise the blood pressure intra-op while still having the IVC exposed..........
Agree with Ron comments........although this modality conveys early survival, its true long lasting use needs further exploration and understanding in order to make it a valid and attractive approach (i.e.. what is the best perfusion pressure under shock state, for how long we allow it, unnecessary bowel anastomisis under this hypotensive state, potential adverse outcomes from persistent acidemia if lower than acceptable perfusion states are maintained intra-op, is this modality only beneficial in vascular injuries or can we use it for solid organ injuries as well.......and so forth) .....I am not trying to kill the concept but we need to open our eyes and be good observers in order to sell it right.........
Great discussion.....Thanks all!

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 McSwain, Norman E Jr.
Sent: Fri 1/30/2009 9:02 AM
To: Trauma &amp; Critical Care mailing list
Subject: RE: Intra-operative Permissive Hypotension

Too often in our rush to get the patient our of the OR and into the ICU
we forget Bernoulli's principle. Hemorrhage is a direct relationship
between the intra-luminal and the extra-luminal pressure. When the
intra-luminal pressure goes up the bleeding likewise does the same if
all of the holes are not closed

Norman

Norman McSwain MD
Professor, Tulane School of Medicine
Trauma Director, Charity Hospital Trauma Center
norman.mcswain at tulane.edu
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Gross, Ronald
Sent: Friday, January 30, 2009 7:41 AM
To: 'Trauma &amp; Critical Care mailing list'
Subject: RE: Intra-operative Permissive Hypotension

We are in agreement - my post was simply a cautionary statement to make
sure that we all remember that in the long run hypotension is not where
we normally live, that some will tolerate it better than others - for a
little while, and that the bleeding must be stopped and a normotensive
state must be restored as soon as possible.

So much for my 2 cents!!

Take care,
Ron

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Pedro Ibarra
Sent: Friday, January 30, 2009 8:28 AM
To: Trauma &amp; Critical Care mailing list
Subject: Re: Intra-operative Permissive Hypotension

I loved Dr Carrick's abstract.
My 2 cents from the other side of the screen. I agree that the
physiological tolerance of hypotension is different for older patients
with co-morbidities, but it is possible to allow hypotension in them
while the bleeding is controlled. We currently can monitor reasonably
well the impact of hypotension on the heart (full ST analysis, and more
effectively, though cumbersome and not readily available, IOP TEE).
OTOH, we can not do as well monitoring the brain, particularly with
carotid stenosis.
In scenarios like ruptured AAA, I have seen that elderly patients with
CAD can tolerate hypotension even in the high 40's of MAP, while
bleeding is controlled and full resuscitation is ensued.

IMHO, monitoring the impact of hypotension can allow its use even in
these sicker patients. This way, on my side of the screen, we can help
improve outcome in these patients.

Sincerely,

Pedro Ibarra MD
Trauma Anesthesia
Bogota, Colombia
> Juan,
> Not trying to sound like I know a lot, but I think, for the benefit of
the "less experienced" on the list, we MUST be cognizant of the baseline
state of the patients we are caring for.  While permissive hypotension
works quite well for the 25 year old soldier (or gang banger, for that
matter) who is in peak physical condition, and mentates as well with a
SBP of 80 as s/he does at 110, the octogenarian with bad CAD who was
just in a car crash, has a Grade IV spleen and lots o' blood in his
abdomen with a SBP of 80 might not tolerate the same resuscitative
measures.
>
> "Good judgment comes from experience.  Experience comes from bad
judgment!"  (Trunkey - sometime in the past)
>
> My best to all,
> Ron
>
> ________________________________
> 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 8:13 PM
> To: Trauma &amp; Critical Care mailing list
> Subject: RE: Intra-operative Permissive Hypotension
>
> 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.
>>
>
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Intra-operative Permissive Hypotension