Turning of(f) the tap!

[Karim Brohi]

Ivan, it's important to remember that coagulopathy, acidaemia and
hypothermia are not the problem.  They are markers of underlying
disturbances in tissue perfusion and activation of inflammation (by which I
especially imply innate immunity including the endothelium, complement, the
inflammatory component of what we understand as 'coagulation' and the innate
cellular response).   As an example, hypothermia doesn't exist because the
room is cold, but because of reduced muscle perfusion, mitochondrial
dysfunction etc etc.  (Hence the important difference between  acquired
hypothermia and induced hypothermia).  Similarly acidaemia is a crude,
global marker for the massive systemic changes that are going on in cellular
function.

Merely giving bicarbonate or THAM is like cutting interest rates to solve
the credit crunch!!!  It fiddles at the edges without in anyway acting on
the underlying (deeper and more complicated) causes, and may indeed lead to
unintended consequences that exacerbate the situation.  But it makes
everyone feel better.

So when we say, 'this patient's physiology is normal because they're not
acidotic, clotting normally and normovolaemic, what we're really saying is
that cellular perfusion and functions are normalising , and that there is no
further ischaemic activation of inflammation and no further reperfusion
events are expected.  So further operative trauma is unlikely to severely
exacerbate the status of the inflammatory systema and if you go ahead and
re-anastomose two piece of bowel, chances are that they'll stay stuck
together!

Karim



On Sat, May 24, 2008 at 4:40 AM, Ivan Hronek <ivanhronek at yahoo.com> wrote:

> Karim,
>
> Hope I'm not confirming my bias now if I say that I agree that acidosis
> persists despite sufficient resuscitation for a while. Other indices of
> homeostasis can I believe be taken care of.
> I do not really think that open body cavities are an issue as temperature
> is not usually a problem - at least not here in Southern California -  and a
> little crystalloid will easily replace the evaporative and other fluid
> losses.
>
> So is it just because of the persisting acidosis that we pack up asap and
> go to the ITU - is that the reason why more patients survive ? Is it just
> because of decreased coagulation problems ? Even if we normalize the pH with
> NaHCO3 or THAM ?
>  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 <karimbrohi at gmail.com>
> To: "Trauma &, Critical Care mailing list" <trauma-list at trauma.org>
> Sent: Friday, May 23, 2008 2:48:27 PM
> Subject: Re: Turning of(f) the tap!
>
> 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-
> > ________________________________
> >
> > Confidentiality Notice: This transmission and any attached documents may
> be
> > confidential and contain information protected by State and Federal
> Medical
> > Privacy statutes and is legally privileged. They are intended for use
> only
> > by the addressee. If you are not the intended recipient of this
> > transmission, or an agent of the intended recipient, you are prohibited
> from
> > reading, disclosing, printing, saving, copying, using, or otherwise
> > disseminating any information contained in this transmission. If you
> > received this transmission in error, please accept our apologies and
> notify
> > me at  ivanhronek at yahoo.comand delete the entire message and its
> > attachments. Thank you. Disclaimer: this message contains the personal
> views
> > of the author. The author will not be responsible in any way for
> procedures
> > or approaches perfomed in the way suggested in this note.
> > ________________________________
> >
> >
> >
> >
> > ----- 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
> >
> >
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