Permissive hypotension

[Radetzky]

Critical care trainee here (in australasia critical care runs both medical and surgical ICUs). I've been hearing a lot recently about the approach of permissive hypotensive, that is permitting SBPs of 60-70 in actively bleeding patients to stop "the clot from popping" and prevent dilutional coagulopathy while waiting for damage control.

I've read the evidence around it and I understand it exists but is underpowered. Wondering what everybodys experience is with this strategy and how you all approach this situation (in both penetrating and blunt)

Look forward to hearing everybody's opinion and maybe some debate.

Cheers

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[HighPriest]

I’ve tried it. Made me feel light headed. Saw Jesus, though. He’s Mexican.

 

[LucidSplash]

This is our approach with ruptured aortas until we have balloon control or a clamp on the aorta. So it makes sense to me that it should apply to trauma as well.

 

[ACSurgeon]

Only if awake and you can follow their neuro status

 

[TypeADissection]

This is our approach with ruptured aortas until we have balloon control or a clamp on the aorta. So it makes sense to me that it should apply to trauma as well.

I believe this approach is by and large adopted from the trauma literature. The crazy thing is the last few ruptures that rolled in all asked beforehand about fluid management and we said to shoot for SBPs 80-100 and don't bomb them with fluid. We meet them at the elevator as they come off the helicopter and there's two bags of saline being slammed into them and a unit of the red sauce. So, there goes that plan.

 

[metzthatcut]

I believe this approach is by and large adopted from the trauma literature. The crazy thing is the last few ruptures that rolled in all asked beforehand about fluid management and we said to shoot for SBPs 80-100 and don't bomb them with fluid. We meet them at the elevator as they come off the helicopter and there's two bags of saline being slammed into them and a unit of the red sauce. So, there goes that plan.

Sounds like our aorta patients who also come in with the norepi drip at 18, sBP of 150 and a transport signout of "blood pressure is pretty good now that we got the levophed going"

 

[ADDmedic]

Sounds like our aorta patients who also come in with the norepi drip at 18, sBP of 150 and a transport signout of "blood pressure is pretty good now that we got the levophed going"

I’m not a physician but slamming Levo, red sauce or crystalloids does not make any sense. I may be an old medic but this does not equate to anything but chasing numbers. Am I wrong?

 

[dpmd]

This was being done when I was in med school and residency. I mean not for every single patient (if the bleeding source is something you can easily control manually then better to do that and then resusc then let them sit with low BP) but definitely better than pouring buckets of fluid and products in that are just going to go on the floor or into a body cavity.

 

[deleted547339]

We do it for trauma. With our AAA, GIB, etc, we’ll usually resuscitate with blood products if they look crappy (yacht, poor cap refill, etc). Vasopressors only if pressure is in the toilet (exception is variceal bleeders as they are sometimes vasoplegic).

 

[dynx]

I think it’s the concensus.