List Archives

Sat Jan 31 11:07:53 GMT 2009

Oh I agree.  Want we want to restore is flow and perfusion, not blood
pressure.  K

2009/1/30 Teperman, Sheldon <Sheldon.Teperman at nbhn.net>

>
>  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
>
> Send trauma-list mailing list submissions to
>        trauma-list at trauma.org
>
> To subscribe or unsubscribe via the World Wide Web, visit
>        http://list.mistral.net/mailman/listinfo/trauma-list
> or, via email, send a message with subject or body 'help' to
>        trauma-list-request at trauma.org
>
> You can reach the person managing the list at
>        trauma-list-owner at trauma.org
>
> When replying, please edit your Subject line so it is more specific than
> "Re: Contents of trauma-list digest..."
>
>
> 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. (
> > > http://aol.com?ncid=emlcntaolcom00000023
> > > > )
> > > > --
> > > > trauma-list : TRAUMA.ORG
> > > > To change your settings or unsubscribe visit:
> > > > http://www.trauma.org/index.php?/community/
> > > >
> > > --
> > > trauma-list : TRAUMA.ORG
> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/index.php?/community/
> > >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
>
>
> ------------------------------
>
> 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>
> >
> > > )
> >
> > > --
> >
> > > trauma-list : TRAUMA.ORG
> >
> > > To change your settings or unsubscribe visit:
> >
> > > http://www.trauma.org/index.php?/community/
> >
> > >
> >
> > --
> >
> > trauma-list : TRAUMA.ORG
> >
> > To change your settings or unsubscribe visit:
> >
> > http://www.trauma.org/index.php?/community/
> >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> > -----------------------------------------
> > CONFIDENTIALITY NOTICE: This email communication and any attachments
> > may contain confidential and privileged information for the use of the
> > designated recipients named above. If you are not the intended
> > recipient, you are hereby notified that you have received this
> > communication in error and that any review, disclosure, dissemination,
> > distribution or copying of it or its contents is prohibited. If you
> > have received this communication in error, please reply to the sender
> > immediately or by telephone at
> > (413) 794-0000 and destroy all copies of this communication and any
> > attachments. For further information regarding Baystate Health's
> > privacy policy, please visit our Internet web site at
> > http://www.baystatehealth.com <http://www.baystatehealth.com/> .
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
> >
> >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
>
>
> ------------------------------
>
> 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
> > > > up-to-date with the latest news. (
> > > http://aol.com?ncid=emlcntaolcom00000023
> > > > )
> > > > --
> > > > trauma-list : TRAUMA.ORG
> > > > To change your settings or unsubscribe visit:
> > > > http://www.trauma.org/index.php?/community/
> > > >
> > > --
> > > trauma-list : TRAUMA.ORG
> > > To change your settings or unsubscribe visit:
> > > http://www.trauma.org/index.php?/community/
> > >
> > --
> > trauma-list : TRAUMA.ORG
> > To change your settings or unsubscribe visit:
> > http://www.trauma.org/index.php?/community/
> >
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
> ------------------------------
>
> 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"
>
> An HTML attachment was scrubbed...
> URL: <
> http://list.mistral.net/pipermail/trauma-list/attachments/20090130/943ab40e/attachment.htm
> >
>
> ------------------------------
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
> End of trauma-list Digest, Vol 67, Issue 47
> *******************************************
> -----------------------------------------
> Visit www.nyc.gov/hhc
>
> CONFIDENTIALITY NOTICE: The information in this E-Mail may be
> confidential and may be legally privileged. It is intended solely
> for the addressee(s). If you are not the intended recipient, any
> disclosure, copying, distribution or any action taken or omitted to
> be taken in reliance on this e-mail, is prohibited and may be
> unlawful. If you have received this E-Mail message in error, notify
> the sender by reply E-Mail and delete the message.
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>

List Archives

For your convenience, find the Trauma List Archive Below

trauma-list Digest, Vol 67, Issue 47-Permissive Hypotension