(no subject)

Mon May 19 11:39:47 BST 2008

Hi Mike,

Just picking up on this thread......Nice save!

I too (or I should say WE) have started to use the 1:1 ratio, as close as we can.  Truth is that I brought this home with me from Baghdad after my "stay" there in 2003, and have had outstanding results usign it since.  I do agree of the need to really follow up on the stuff that Holcomb and Spinella have published with some really good studies in the civilian world.

As to the duodenum, a would protect it and to me it wouldn't really matter whether I did it at the 1st or 2nd operation.  either way, I would lay the TA-60 across the pre-pyloric region, fire and NOT cut - no sense making a hole in the stomach to sew the pylorus shut if there wasn't a hole there to begin with.

Just my 2 cents,
Ron

>>> "Sise, Mike MD" <Sise.Mike at scrippshealth.org> 5/18/2008 10:25 PM >>>
Juan,

Thanks for the advice on the duodenum.

 We limit crystalloid to what it takes to keep the blood tubing clear - usually less than 2 liters normal saline. Two week ago I repaired a ruptured AAA who presented with a pressure of 60 and most of his blood volume in his retroperitoneum. To the OR in 5 minutes and no fluid until I had a clamp on his aorta. We gave 8 units pRBCs, 1.5 units cell saver, 8 units FFP, 12 pack of platelets, and 1,200 cc normal saline. He entered the OR with a base deficit of  -13 and left the OR with a damage control closure, a base deficit of -2 with a normal INR and no further bleeding. Had to bolus some normal saline the first day but was able to close him on the 2nd postop day and he did not develop ARDS. 

1:1 seems to work but is it because we give blood or because we limit crystalloids - especially Ringer's lactate? We all need more studies to make sure that 1:1 is not the latest "American Idol" of trauma care.

Mike Sise

________________________________

From: Duchesne, Juan C [mailto:jduchesn at tulane.edu] 
Sent: Sun 5/18/2008 5:56 PM
To: Trauma &amp; Critical Care mailing list; trauma-list at trauma.org 
Cc: Sise, Mike MD
Subject: RE: (no subject)

Mike- Good case. For 4th portion duodenal injury stapling the pylorus on the first phase of Damage Control (DC) might create (compromise the patient) more trouble than good at this time. If necessary I will do it on my second trip back to the OR (Third Phase of DC) in conjunction with a gastrojejunostomy...... if any question regarding my repair .
Attached I placed couple of cases where we used TA-60 stapler at the pylorus without cutting plus wide drainage.
Mike- 
Good to hear more people using damage control resuscitation (DCR) with close ratio's for patients with severe hemorrhage..........
How much Crystalloids you guys allowed anesthesia to give while on DCR mode.........we have drastically lowered crystalloids use in this group of patients from average of 14L to 2.2L.....A BIG DIFFERENCE.

Nice to hear from you
Juan
CharityOne

________________________________

From: trauma-list-bounces at trauma.org on behalf of KMATTOX at aol.com 
Sent: Sun 5/18/2008 7:05 PM
To: trauma-list at trauma.org 
Cc: sise.mike at scrippshealth.org 
Subject: Re: (no subject)

I personally would NOT close the pylorus on this first  operation.  If I did,
I would reach through the open stomach and grab  the pyloric ring with a
Dexon suture (an 0 or 00)    and occlude  it.  

k

In a message dated 5/18/2008 6:46:13 P.M. Central Daylight Time, 
Sise.Mike at scrippshealth.org writes:

Duodenal  injuries - when to interrupt the pylorus and how to do it.

Difficult  duodenal repair for injury to the 4th portion not involving the
pancreas and  remote to the ampulla. Through and through 45 caliber gunshot
wound suture  closure but concern for the repair. Vena cava also repaired. 12
units of  pRBCs, 12 of FFP and, a 12 pack of platelets. Planning a temporary
abdominal  wall closure. Do you interrupt the pylorus and, if so, how do you do  it.

Mike Sise
San Diego

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