Turning of(f) the tap!

[Timothy Craig Hardcastle]

And as usual it comes down to dealing with the 3H's: Hypoxia,
hypoperfusion and hypothermia!!!!

Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban
 
Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal
 
timothyhar at ialch.co.za 
 

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Pradeep Navsaria
Sent: 24 May 2008 17:30
To: trauma-list at trauma.org
Subject: Re: Turning of(f) the tap!

Well said - at last someone who understands the concept and principles
of DCS!

PH Navsaria
Cape Town
South Africa

 >>> "Karim Brohi" <karimbrohi at gmail.com> 05/24/08 13:23 PM >>>
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-
> ________________________________
>
> 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 <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
> >
> >
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
>
>
>
> --
> trauma-list : TRAUMA.ORG
> To change your settings or unsubscribe visit:
> http://www.trauma.org/index.php?/community/
>
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/
--
trauma-list : TRAUMA.ORG
To change your settings or unsubscribe visit:
http://www.trauma.org/index.php?/community/