Turning of(f) the tap!

[Karim Brohi]

Ivan,

I think you read my message to confirm your own bias.  I do not have a
stance on OR resuscitation being better than current damage control practice
of ICU resuscitation.  At the moment this is the best we have.

The problem currently is that for the **actively bleeding** patient, current
resuscitation capabilities can only do so much.  Over resuscitation during
active haemorrhage makes things worse (much worse).  We are unable to
maintain homeostasis during this acute period.  Further, once haemorrhage
has stopped in may take some hours to restore normal physiology to these
patients. Trying to do it with open cavities is much harder and takes much
longer.  It is a bad use of OR time to have a patient sit there for hours
waiting to normalise physiology, so they go to ICU and come back.

I can envision a time when we have directed interventions to avoid this loss
of homeostasis.  But we're nowhere near there yet and damage control with
staged operations is the current gold standard.

Karim

On Fri, May 23, 2008 at 2:25 PM, Ivan Hronek <ivanhronek at yahoo.com> wrote:

> Karim,
>
> I fully agree with your stance on OR resuscitation: I am going to be iconoc
> lastic again and will maintain alongside with you that it is a fallacy that
> ITU resuscitation is better than OR resuscitation.
> It fits in the 'damage control' surgery approach, which may be OK; however
> we should not be fooling ourselves and say it is a good approach because of
> ITU resuscitation being better than OR resuscitation.
> Is the damage control approach so much better for other reasons then ? What
> are those reasons ?
> Ivan Hronek
> MD
> SFMC, Los Angeles, CA                                                Do not
> fear to be eccentric in opinion, for every opinion now
> accepted was once eccentric. - Bertrand Russell-
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> ----- Original Message ----
> From: Karim Brohi <karim at trauma.org>
> To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
> Sent: Tuesday, May 20, 2008 2:13:06 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
>
>