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Sat Jan 31 21:41:02 GMT 2009

Matt- Thanks for joining the discussion. I was really encourage with your presentation at EAST. Please keep us up to date on your important work!  As we discussed at EAT, Damage Control Resuscitation works not just because of early hemostatic resuscitation but rather when the sum of its component (i.e.. low volume resuscitation, permissive hypotension) are started early in conjunction with ground zero damage control interventions. One important missing link is to better define and understand the best allowable perfusion pressure that will still allow an effective intra-operative resuscitation. This perfusion pressure will convey similar or better outcomes from standard "shoot from the hip" approaches.

Good Job!
Juan

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 Carrick, Matthew M.
Sent: Sat 1/31/2009 2:22 PM
To: Trauma &amp; Trauma &amp, Critical Care mailing list
Subject: RE: Intra-operative Permissive Hypotension and Intra-operativePermissive Hypotension - How do you

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. (
> > > http://aol.com?ncid=emlcntaolcom00000023 <http://aol.com/?ncid=emlcntaolcom00000023>  <http://aol.com/?ncid=emlcntaolcom00000023>  <
> http://aol.com/?ncid=emlcntaolcom00000023>
> > > > )
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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>  <
> > http://aol.com/?ncid=emlcntaolcom00000023>
> >
> > > )
> >
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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
> > > > 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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> ------------------------------
>
> 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
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