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Permissive Hypotension

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Damage Control Resuscitation

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Abstract

Permissive hypotension in the context of life-threatening haemorrhage is a resuscitation strategy which is used within damage control resuscitation, in which a lower than normotensive blood pressure is targeted until the source of haemorrhage is controlled. The perceived benefit of permissive hypotension is that it limits bleeding and prevents dislodging of any clot formed at the injury site by avoiding excessively high blood pressures.

The dangers of large fixed-volume fluid resuscitation were highlighted throughout the twentieth century; however, it was not until the turn of the century where various strategies limiting crystalloid resuscitation started to emerge. This included volume restricting, delaying fluid administration or titrating fluid administration to a lower than normal systolic blood pressure.

A balance needs to be struck between an exacerbating bleeding and the accumulation of the effects of prolonged hypoperfusion and shock. Novel hybrid resuscitation and the availability of blood products in the pre-hospital environment are natural progressions in the concept of damage control resuscitation and may form the next iteration of new resuscitation strategies.

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References

  1. Wiles MD. Blood pressure management in trauma: from feast to famine? Anaesthesia. 2013;68:445–9.

    Article  CAS  Google Scholar 

  2. Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma. 2007;62(2):307–10.

    Google Scholar 

  3. White NJ, Ward KR, Pati S, Strandenes G, Cap AP. Hemorrhagic blood failure: oxygen debt, coagulopathy, and endothelial damage. J Trauma Acute Care Surg. 2017;82(6S Suppl 1):S41–9.

    Article  Google Scholar 

  4. Bjerkvig CK, Strandenes G, Eliassen HS, Spinella PC, Fosse TK, Cap AP, Ward KR. “Blood failure” time to view blood as an organ: how oxygen debt contributes to blood failure and its implications for remote damage control resuscitation. Transfusion. 2016;56(Suppl 2):S182–9.

    Article  CAS  Google Scholar 

  5. Cothren CC, Moore EE, Hedegaard HB, Meng K. Epidemiology of urban trauma deaths: a comprehensive reassessment 10 years later. World J Surg. Springer-Verlag. 2007;31(7):1507–11.

    Article  Google Scholar 

  6. World Health Organization. World Health Organisation: cause-specific mortality and morbidity (p. 59–71) [Internet]. 2010. p. 1–177. Available from: http://www.who.int/whosis/whostat/EN_WHS10_Full.pdf.

  7. Dunham CM, Siegel JR, Weireter L, et al. Oxygen debt and metabolic acidemia as quantitative predictors of mortality and the severity of the ischaemic insult in hemorrhage shock. Crit Care Med. 1991;19:1.

    Article  Google Scholar 

  8. Wiggers CJ. The failure of blood transfusions in irreversible hemorrhagic shock. Am J Phys. 1945;144:91–101.

    Article  Google Scholar 

  9. Wiggers HC, Ingraham RC, Roemhild F, Goldberg H. Vasoconstriction and the development of irreversible hemorrhagic shock. Am J Phys. 1948;153:511–20.

    Article  CAS  Google Scholar 

  10. Reynolds M. Cardiovascular effects of large volumes of isotonic saline infused intravenously into dogs following severe hemorrhage. Am J Phys. 1949;158:418–28.

    Article  CAS  Google Scholar 

  11. Shires T, Coln D, Carrico J, Lightfoot S. Fluid therapy in hemorrhagic shock. AMA Arch Surg. 1964;88:688–93.

    Article  CAS  Google Scholar 

  12. American College of Surgeons Committee on Trauma. Advanced trauma life support (ATLS) course for physicians. Chicago: American College of Surgeons; 1997. p. 87–106.

    Google Scholar 

  13. Moylan JA, Mason AD, Rogers PW, Walker BL. Post burn shock: a critical evaluation of resuscitation. J Trauma Inj Infect Crit Care. 1973;13:354–8.

    Article  CAS  Google Scholar 

  14. Baxter C. Fluid volume and electrolyte changes in the early post-burn period. Clin Plastic Surg. 1974;1:698–703.

    Google Scholar 

  15. Morton A. Traumatic pulmonary insufficiency and non-mechanical bleeding in battle casualties. Aust N Z J Surg. 1971;40:356–9.

    Article  CAS  Google Scholar 

  16. Fietsam R, Villalba M, Glover JL, Clark K. Intra-abdominal compartment syndrome as a complication of ruptured abdominal aortic aneurysm repair. Am Surg. 1989;55(6):396–402.

    PubMed  Google Scholar 

  17. Cannon WB, Fraser J, Cowell EM. The preventive treatment of wound shock. JAMA. 1918;70:618–21.

    Google Scholar 

  18. Bickell WH, Bruttig SP, Millnamow GA, O’Benar J, Wade CE. The detrimental effects of intravenous crystalloids after aortotomy in swine. Surgery. 1991;110:529–36.

    CAS  PubMed  Google Scholar 

  19. Solomonov E, Hirsh M, Yahiya A, Krausz MM. The effect of vigorous fluid resuscitation in uncontrolled hemorrhagic shock following massive splenic injury. Crit Care Med. 2000;28:749–54.

    Article  CAS  Google Scholar 

  20. Gross D, Landau EH, Klin B, Krausz MM. Treatment of uncontrolled hemorrhagic shock with hypertonic saline solution. Surg Gynecol Obstet. 1990;170:106–12.

    CAS  PubMed  Google Scholar 

  21. Dunham CM, Belzberg H, Lyles R, Weireter L, Skurdal D, Sullivan G, et al. The rapid infusion system: a superior method for the resuscitation of hypovolemic trauma patients. Resuscitation. 1991;21(2–3):207–27.

    Article  CAS  Google Scholar 

  22. Duke MD, Guidry C, Guice J, Stuke L, Marr AB, Hunt JP, et al. Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation. J Trauma Acute Care Surg. 2012;73(3):674–8.

    Article  CAS  Google Scholar 

  23. Schreiber MA, Meier EN, Tisherman SA, Kerby JD, Newgard CD, Brasel K, et al. A controlled resuscitation strategy is feasible and safe in hypotensive trauma patients: results of a prospective randomized pilot trial. J Trauma Acute Care Surg. 2015;78(4):687–95; discussion 695–7.

    Article  Google Scholar 

  24. Kaweski SM, Sise MJ, Virgilio RW. The effect of prehospital fluids on survival in trauma patients. J Trauma. 1990;30:1215–8.

    Article  CAS  Google Scholar 

  25. Bickell WH, Wall MJ, Pepe PE. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331:1105–9.

    Article  CAS  Google Scholar 

  26. Kowalenko T, Stern SA, Dronen SC, Wang X. Improved outcome with hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine model. J Trauma. 1992;33:349–53.

    Article  CAS  Google Scholar 

  27. Mapstone J, Roberts I, Evans P. Fluid resuscitation strategies: a systematic review of animal trials. J Trauma. 2003;55(3):571–89.

    Article  Google Scholar 

  28. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma Acute Care Surg. 2002;52(6):1141–6.

    Article  Google Scholar 

  29. Morrison CA, Carrick MM, Norman MA, Scott BG, Welsh FJ, Tsai P, et al. Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011;70(3):652–63.

    Article  Google Scholar 

  30. Carrick MM, Morrison CA, Tapia NM, Leonard J, Suliburk JW, Norman MA, et al. Intraoperative hypotensive resuscitation for patients undergoing laparotomy or thoracotomy for trauma: early termination of a randomized prospective clinical trial. J Trauma Acute Care Surg. 2016;80(6):886–96.

    Article  Google Scholar 

  31. Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993;34(2):216–22.

    Article  CAS  Google Scholar 

  32. Kwan I, Bunn F, Chinnock P, Roberts I. Timing and volume of fluid administration for patients with bleeding. Cochrane Database Syst Rev. 2014;(3):CD002245.

    Google Scholar 

  33. Kanani AN, Hartshorn S. NICE clinical guideline NG39: major trauma: assessment and initial management. Arch Dis Child Educ Pract Ed. Royal College of Paediatrics and Child Health. 2017;102(1):20–3.

    Article  Google Scholar 

  34. Spahn DR, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernandez-Mondejar E, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care (London, England). 2013;17(2):R76.

    Article  Google Scholar 

  35. Greaves I, Porter KM, Revell MP. Fluid resuscitation in pre-hospital trauma care: a consensus view. J R Coll Surg Edinb. 2002;47:451–7.

    CAS  PubMed  Google Scholar 

  36. Quinn D, Frith D. Assessing the damage control resuscitation: development, drivers and direction. Emerg Med Australas. 2015;27:485–7.

    Article  Google Scholar 

  37. Carrick MM, Leonard J, Slone DS, Mains CW, Bar-Or D. Hypotensive resuscitation among trauma patients. Biomed Res Int. 2016;2016:8901938.

    Article  Google Scholar 

  38. Stein P, Kasere A, Sprengel K, et al. Change of transfusion and treatment paradigm in major trauma patients. Anaesthesia. 2017;72:1317–26.

    Article  CAS  Google Scholar 

  39. Bridges LC, Waibel BH, Newell MA. Permissive hypotension: potentially harmful in the elderly? A national trauma data bank analysis. Am J Surg. 2015;81:770–7.

    Google Scholar 

  40. Brunauer A, Kokofer A, Bataar O, Gradwohl-Matis I, Dankl D, Dunser MW. The arterial blood pressure associated with terminal cardiovascular collapse in critically ill patients: a retrospective cohort study. Crit Care. 2014;18:719.

    Article  Google Scholar 

  41. Emerson CP, Ebert RV. A study of shock in battle casualties: measurements of the blood volume changes occurring in response to therapy. Ann Surg. 1945;122(5):745–72.

    Article  CAS  Google Scholar 

  42. Eastridge BJ, Salinas J, McManus JG, Blackburn L, Bugler EM, Cooke WH, et al. Hypotension begins at 110 mm Hg: redefining “hypotension” with data. J Trauma Acute Care Surg. 2007;63(2):291–7; discussion 297–9.

    Article  Google Scholar 

  43. Hasler RM, Nuesch E, Jüni P, Bouamra O, Exadaktylos AK, Lecky F. Systolic blood pressure below 110 mmHg is associated with increased mortality in blunt major trauma patients: multicentre cohort study. Resuscitation. 2011;82(9):1202–7.

    Article  Google Scholar 

  44. Li T, Zhu Y, Hu Y, Li L, Diao Y, Tang J, et al. Ideal permissive hypotension to resuscitate uncontrolled hemorrhagic shock and the tolerance time in rats. Anesthesiology. The American Society of Anesthesiologists. 2011;114(1):111–9.

    Google Scholar 

  45. Skarda DE, Mulier KE, George ME, Bellman GJ. Eight hours of hypotensive versus normotensive resuscitation in a porcine model of controlled hemorrhagic shock. Acad Emerg Med. 2008;15(9):845–52.

    Article  Google Scholar 

  46. Wiles M. Blood pressure in trauma resuscitation: ‘pop the clot’ vs. ‘drain the brain’? Anaesthesia. 2017;72:1448–55.

    Article  CAS  Google Scholar 

  47. Pigula FA, Wald SL, Shackford SR, Vane DW. The effect of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg. 1993;28:310–6.

    Article  CAS  Google Scholar 

  48. Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80:6–15.

    Google Scholar 

  49. Stern SA, Zink BJ, Mertz M, Wang X, Dronen SC. Effect of initially limited resuscitation in a combined model of fluid percussion brain injury and severe uncontrolled haemorrhage shock. J Neurosurg. 2000;93:305.

    Article  CAS  Google Scholar 

  50. Hu Y, Wu Y, Tian K, et al. Identification of ideal resuscitation pressure with concurrent traumatic brain injury in a rat model of haemorrhage shock. J Surg Res. 2015;195:284–93.

    Article  Google Scholar 

  51. Gunnar W, Jonasson O, Merlotti G, Stone J, Barrett J. Head injury and haemorrhage shock: studies of the blood brain barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran-40. Surgery. 1988;103:398.

    CAS  PubMed  Google Scholar 

  52. Hariri RJ, Firlick AD, Shepard SR, et al. Traumatic brain injury, haemorrhage shock, and fluid resuscitation: effects on intracranial pressure and brain compliance. J Neurosurg. 1993;79:421.

    Article  CAS  Google Scholar 

  53. Vrettos T, Poimenidi E, Athanasopoulos P, et al. The effect of permissive hypotension in combined traumatic brain injury and blunt abdominal trauma: an experimental study in swines. Eur Rev Med Pharmacol Sci. 2016;20:620–30.

    CAS  PubMed  Google Scholar 

  54. Glen J, Constanti M, Brohi K, Guideline Development Group. Assessment and initial management of major trauma: summary of NICE guidance. Br Med J. 2016;22:353.

    Google Scholar 

  55. Garner J, Watts S, Parry C, Bird J, Cooper G, Kirkman E. Prolonged permissive hypotensive resuscitation is associated with poor outcome in primary blast injury with controlled hemorrhage. Ann Surg. 2010;251(6):1131–9.

    Article  Google Scholar 

  56. Kirkman E, Watts S, Cooper G. Blast injury research models. Philos Trans R Soc Lond Ser B Biol Sci. 2011;366(1562):144–59.

    Article  CAS  Google Scholar 

  57. Shackelford SA, del Junco DJ, Powell-Dunford N, Mazuchowski EL, Howard JT, Kotwal RS, et al. Association of prehospital blood product transfusion during medical evacuation of combat casualties in Afghanistan with acute and 30-day survival. JAMA. 2017;318(16):1581–91.

    Article  Google Scholar 

  58. Woolley T, Thompson P, Kirkman E, Reed R, Ausset S. Trauma Hemostasis and Oxygenation Research (THOR) Network position paper on the role of hypotensive resuscitation as part of remote damage control resuscitation. J Trauma Acute Care Surg. 2018;84:S3–S13. Volume ahead of print.

    Article  Google Scholar 

  59. Watts S, Nordmann G, Brohi K, Midwinter MJ, Woolley T, Gwyther R, et al. Evaluation of prehospital blood products to attenuate acute coagulopathy of trauma in a model of severe injury and shock in anesthetized pigs. Shock. 2015;44(Suppl 1):138–48.

    Article  Google Scholar 

  60. Brown JB, Sperry JL, Fombona A, Billiar TR, Peitzman AB, Guyette FX. Pre-trauma center red blood cell transfusion is associated with improved early outcomes in air medical trauma patients. J Am Coll Surg. 2015;220(5):797–808.

    Article  Google Scholar 

  61. Rehn M, Weaver AE, Eshelby S, Røislien J, Lockey DJ. Pre-hospital transfusion of red blood cells in civilian trauma patients. Transfus Med. 2018;28:457.

    Article  Google Scholar 

  62. Holcomb JB, Donathan DP, Cotton BA, del Junco DJ, Brown G, Wenckstern TV, et al. Prehospital transfusion of plasma and red blood cells in trauma patients. Prehosp Emerg Care. 2015;19(1):1–9.

    Article  Google Scholar 

  63. Hanson JM, Van Hoeyweghen R, Kirkman E, Thomas A, Horan MA. Use of stroke distance in the early detection of simulated blood loss. J Trauma. 1998;44(1):128–34.

    Article  CAS  Google Scholar 

  64. Nevin DG, Brohi K. Permissive hypotension for active haemorrhage in trauma. Anaesthesia. 2017;72:1443–8. https://doi.org/10.1111/anae.14034.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anaesthesia, James Cook University Hospital, Middlesbrough, UK

    Allan Pang

  2. Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK

    Allan Pang, Ravi Chauhan & Tom Woolley

  3. Department of Anaesthesia, University Hospital Birmingham, Birmingham, UK

    Ravi Chauhan

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  1. Allan Pang
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  2. Ravi Chauhan
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  3. Tom Woolley
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Correspondence to Allan Pang .

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  1. School of Medicine, Washington University in St. Louis, St. Louis, MO, USA

    Philip C. Spinella

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Pang, A., Chauhan, R., Woolley, T. (2020). Permissive Hypotension. In: Spinella, P. (eds) Damage Control Resuscitation. Springer, Cham. https://doi.org/10.1007/978-3-030-20820-2_6

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  • DOI: https://doi.org/10.1007/978-3-030-20820-2_6

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