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Permissive Hypotension
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Also called “Controlled Resuscitation” “Balanced Resuscitation” “Hypotensive Resuscitation” and “Permissive Hypotension.”
- In blunt trauma – fluid resuscitation and avoidance of hypotension are important principles in initial management.
- In Penetrating trauma – delaying aggressive fluid resuscitation until definitive haemorrhage will prevent excessive blood loss and maintain permissible hypotension.
- Permissive Hypotension is a bridging resuscitation strategy to definitive haemorrhage control.
- In Grade III & IV shock – early blood and blood product transfusion (PRBC, FFP, & Platelets) in the ratio of 1:1:1 or a low ratio of Blood and FFP & platelets (which means more blood products) reduces the chances of trauma-induced coagulopathy.
- Before definitive haemorrhage control, maintain systolic blood pressure <90 mmHg with blood & blood products.
- Overzealous crystalloids and vasopressors kill patients sooner or later.
- Colloids are contraindication is traumatic shock or any shock and associated with higher mortality and acute kidney injury.
- Permissive hypotension is maintaining low permissible blood pressure in penetrating or selected blunt trauma patients (except head injury) to prevent excessive blood loss before definitive haemorrhage control.
- Aggressive fluid resuscitation promotes excessive bleeding by displacement of established clots and is associated with increased mortality.
- Overzealous crystalloids, colloids and inotropes are contraindicated in trauma patients.
- Recommended fluid is 1 litre of warm Ringer Lactate given through a wide bore cannula.
- Dextrose containing fluids (5% Dextrose, DNS) are contraindicated in moderate or severe head injury patients. Ringers lactate should be avoided in severe head injury patients.
- In head injury – Normal saline is the fluid of choice. Systolic blood pressure (SBP) should be maintained at more than 90mm Hg, and cerebral perfusion pressure (CPP) should be more than 60mm Hg.
Contraindication for balanced resuscitation or permissive hypotension
- Polytrauma patients with severe haemorrhage
- Head injury
- Suspected head injury, associated with polytrauma
- Any blunt injury with multiple sources of bleeding.
References
- Das JM, Anosike K, Waseem M. Permissive Hypotension. InStatPearls [Internet] 2021 Feb 10. StatPearls Publishing.
- Kudo D, Yoshida Y, Kushimoto S. Permissive hypotension/hypotensive resuscitation and restricted/controlled resuscitation in patients with severe trauma. Journal of Intensive Care. 2017 Dec;5(1):1-8.
- Nevin DG, Brohi K. Permissive hypotension for active haemorrhage in trauma. Anaesthesia. 2017 Dec;72(12):1443-8.
