Pre-hospital fluid therapy.

[JOSE SUAREZ PELAEZ]

Dear Dr. Mattox,



Thank you for your comments. The objective of my email was to hear different 
opinions from colleagues on certain issues.



I believe that while SBP continues to be used as the main therapeutic 
objective in bleeding patients, while the means/devices to measure SBP are 
maintained and not replaced/complemented by other more sensitive measures 
(SLCO2, NIRS, etc) to detect acceptable perfusion indicating 
non-administration of fluids (to avoid greater hemorhage, re-bleeding and/or 
a systemic inflammatory response due to unnecessary fluid administration), 
SBP will continue to constitute the golden objective in pre-hospital 
treatment and set back the day when bleeding patients are not given 
excessive quantities of fluid that may result in devastating consequences, 
whether immediate or not.



You and other experts have warned about the limitations of SBP as 
therapeutic objective and have proposed the use of permissive hypotension. 
However, quantities of isotonic fluids >750 ml may continue to be 
administered. I think the didactic use of the concept permissive hypovolemia 
(and not hypotension) might help to reduce excessive administration of 
fluids: attempting to provide each patient with only what he/she needs, 
specially in children.



There are sufficient arguments against the need to normalise BP in bleeding 
patients. I think the scientific community is tending towards this 
viewpoint.  But how to ensure the administration of the necessary fluid to 
achieve a balance between damage and benefit? As the Dutton study has shown, 
this is complicated.



Perhaps, as you propose, 50 ml boluses using radial pulse and state of 
consciousness as endpoints, regardless of BP, could prevent situation like 
following: my nurse Toñi usually has BP of 70, in the event of an accident, 
she could be hypotensive, tachycardic, anxious, etc, so, she would probably 
receive excessive fluid possibly causing increased bleeding, re-bleeding, 
iatrogenic respiratory distress, or even multi-organ failure and death, 
after hemorhage control and a "normal" BP.



Therefore I believe we should start to use the term Permissive Hypovolemia, 
not merely for semantic reasons but because of its conceptual and didactic 
usefulness.



I would be grateful for any comments you may have (pro or cons)





José Suarez-Peláez






----- Original Message----- 
From: <KMATTOX at aol.com>
To: <trauma-list at trauma.org>
Sent: Tuesday, June 05, 2007 12:09 PM
Subject: Re: Pre-hospital fluid therapy.



In a message dated 6/5/2007 5:27:34 A.M. Central Daylight Time,
josuarez at teleline.es writes:

José  Suarez-Peláez



Dr.  Jose Suarez-Pelaez has asked this group to respond to an article  and a
letter to the editor in the journal, "Injury."    The  letter contains some
germane observations and questions.    Particularly, the question of the 
value
of systemic blood pressure as a measure  of adequacy of resuscitation,
perfusion, etc. is right on.     However, for the majority of the world, 
this readily
available device is what is  available, and Near Infrared Spectroscopy has 
not
yet been  standardized.

I would agree that in the referenced study, the inclusion criteria are two
broad and using a BP of 90/- systolic, or better 70/- as an entry criteria 
for
such studies would be more appropriate.

K Mattox



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