Turning of(f) the tap!

Tue May 20 16:23:18 BST 2008

Karim,
Thank you for the unfortunate spelling correction, although I did consider that a few radical list members may wish to turn the tap on rather than off ....someone will always disagree!!

But more importantly thank you for addressing the issues raised.....my whole point was to generate such a discussion and to stir the list. Sadly, are you the only one prepared to stick your head up and be counted? 
'Ever the optimist', I hope we get a few more views....and of course that 'proven' list!!

Regards
Mark F
UK

----- Original Message ----
From: Karim Brohi <karim at trauma.org>
To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
Sent: Tuesday, 20 May, 2008 10:13:06 AM
Subject: Re: Turning of(f) the tap!

Mark:

Do we really know the things we think we definitely know?

So can the list members consider what is accepted or agreed ? What we do
> know?
> - your own blood is the best fluid in your vessels?

Initially yes.  Afterwards perhaps not.  If you believe in 1:1, then whole
blood is only 1:2.  Also your own blood is almost certainly better than
someone elses, due to its immunogenicity.  There may also be real activation
of inflammatory factors in shed blood.???

>
> - hypothermia is a greatly under-estimated problem and must be aggressively
> avoided

Unless its induced hypothermia in which case it may be life saving????

>
> -Damage control surgery is a good thing

At the moment - but if we could get better at maintaining homeostasis, would
we still recommend it.  Will we still be doing damage control in 10 years
time?

>
> -Haemoglobin of 7-8g/dl is an acceptable target for transfusion

ICU studies would say 6.  Is it the same if you're in shock and actively
bleeding?

-Excessive crystalloid or colloid is not good - 'cyclic hypersuscitation'

Can't argue with this one - except that it's not just cyclic
hyperresuscitation and that excessive any fluid is probably bad

>
> -ITU is the place for defintive resuscitation after damage control

Again.  Shouldn't we be getting better at maintaining homestasis in the OR?
If you could close temporarily and correct physiology in the OR perhaps you
could reopen after 30 minutes or so and complete????

>
> - Once you have a significant coagulopathy you have 'missed the boat'?

Well since 1 in 4 patients arrive with a coagulopathy this would be bad.  We
need to find an optimal way of getting the boat to turn back and pick them
up. Especially if we can unravel the mechanism of this coagulopathy and
develop inhibitors to it (rather than our current strategy of pouring in
more and more clotting factors)

>
>
> I am sure that we could all come up with a reliable and agreed list...dare
> I say 'proven'!

Ever the optimist!!!

Karim

>
>
>
> ----- Original Message ----
> From: Ronald Gross <Rgross at harthosp.org>
> To: trauma-list at trauma.org; Juan C Duchesne <jduchesn at tulane.edu>
> Sent: Monday, 19 May, 2008 11:39:47 AM
> Subject: RE: (no subject)
>
> 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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