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TBI

Guy Jackson r.g.m.jackson at qmul.ac.uk
Thu Oct 27 17:57:10 BST 2005


This reminds me of a paper from 1998, that despite being in (I think) NEJM
gained an editorial comment in (I think) The Lancet. The paper for many
needs only the first and last paragraph reading. The first says that the
authors tried to do a randomised controlled trial of PA catheters but nobody
would let them so they devised a method to see if they seemed to be useful
and not dangerous. The last paragraph states that on the evidence presented
the authors believe that a prospective randomised controlled trial is
indicated.

The situation is similar here. Folks tend either to insist on goal directed
therapy, or think it unproven, or even dangerous. This paper starts with the
premise that there is no RCT. The authors then devise a system to get some
sort of comparison, point out all the problems, and call for a prospective
RCT. The associated editorial is a good summary of the arguments.

Personally, I disagree with the authors that the dead and good recovery in
24 hour groups should be excluded. Perhaps they should be a sub-group where
adverse events are recorded to help with the risk/benefit analysis, but the
latter is essential unless we can predict these outcomes on admission.

The irony is that they produced some evidence (buy not a RCT) supporting the
Lund Hypothesis, but few others agree.

Guy Jackson
London UK

----- Original Message ----- 
From: "Tchaka Shepherd" <tshepherdmd at hotmail.com>
To: <trauma-list at trauma.org>
Sent: Thursday, October 27, 2005 3:33 PM
Subject: Re: TBI


> Reference: " Effect of intracranial pressure monitoring and targeted
> intensive care on functional outcome after severe head injury"  CRITICAL
> CARE MEDICINE. 33 (10) 2207-2213 OCTOBER 2005
>
>                              T.Shepherd
>
>                               Los Angeles
>
>
> >From: "Ian Seppelt" <SeppelI at wahs.nsw.gov.au>
> >To: <tshepherdmd at hotmail.com>
> >Subject: Re: TBI
> >Date: Thu, 27 Oct 2005 16:52:42 +1000
> >
> >What is the reference, please
> >
> >Ian Seppelt FANZCA FJFICM
> >Staff Specialist in Intensive Care Medicine
> >The Nepean Hospital,
> >PO Box 63, Penrith NSW 2751
> >Clinical Lecturer, University of Sydney
> >
> >
> > >>> tshepherdmd at hotmail.com 10/27/05 03:19pm >>>
> >Recent article out of the netherlands-- Objective was to determine the
> >effect of ICP/CPP targeted intensive care on functional outcome and
therapy
> >intensity levels after severe head injury. To make this brief their
> >conclusion which is pretty compelling ---" we were unable to demonstrate
a
> >trend toward a more favorable functional outcome with the use of an
ICP/CPP
> >targeted critical care protocol" Obviously not a randomized-controlled
> >prospective trials but still extremely fascinating. During my fellowship
> >training we aggressively treated ICP/CPP although there is truly no good
> >data to support this.  I was hoping for a few comments. What are the
> >opinions regarding the best way to managed Severe TBI?  Why not perform a
> >randomized controlled trial?  Is it truly unethical if we could provide
> >some
> >insight in to the appropriate management of neurotrauma?
> >
> >                T. Shepherd
> > >From: "Ian Seppelt" <SeppelI at wahs.nsw.gov.au>
> > >Reply-To: Trauma & Critical Care mailing list <trauma-list at trauma.org>
> > >To: <tangentcarrot at hotmail.com>, <trauma-list at trauma.org>
> > >Subject: Re: Colloid infusion in the trauma patient
> > >Date: Thu, 27 Oct 2005 11:56:11 +1000
> > >
> > >Big world of caution:
> > >
> > >You will recall that in SAFE (New Engl J Med 2004, 350:2247-2256) the a
> > >priori trauma subgroup (17.3% of 7000 patients, making it the biggest
> >ever
> > >trauma fluid study) showed evidence of harm when albumin was given to
> > >trauma patients. On subgroup analysis this harm appeared to be
restricted
> > >to those with a traumatic brain injury. A 2 year followup of these TBI
> > >patients has been analysed and is about to be published and you should
> >all
> > >look very closely at the results (I can't say more until it hits the
> > >press).
> > >
> > >The other big message from SAFE is that the 3:1 colloid to crystalloid
> > >ratio that we are taught in books (which comes from healthy volunteer
> >dogs
> > >in the 1950s) is utter rubbish when applied to sick humans. In every
> > >subgroup there was a consistent 1.4:1 ratio (volume of albumin conpared
> >to
> > >volume of saline, to acheive a clinical resuscitation endpoint). This
> >will
> > >creep into the books eventually.
> > >
> > >For now I think it is fair to say that anyone who gives colloids to a
> > >trauma patient in ICU is being very unwise!
> > >
> > >Cheers, Ian
> > >
> > >Ian Seppelt FANZCA FJFICM
> > >Staff Specialist in Intensive Care Medicine
> > >The Nepean Hospital,
> > >PO Box 63, Penrith NSW 2751
> > >Clinical Lecturer, University of Sydney
> > >
> > >
> > > >>> tangentcarrot at hotmail.com 10/23/05 01:24am >>>
> > >Actually, niyher do us.
> > >But it is available for use with patients who's transfer to the
hospital
> >is
> > >greatly delayed (not saying that it will be used in such a case, only
> >that
> > >it's available. It's for doctor to decide, as much as I can recall it's
> >not
> > >indicated by some protocol or something)
> > >
> > >Do you use it with trauma patients in the ICU?
> > >
> > >
> > >
> > > >From: flysurg at aol.com
> > > >Reply-To: Trauma & Critical Care mailing list
<trauma-list at trauma.org>
> > > >To: trauma-list at trauma.org
> > > >Subject: Re: Colloid infusion in the trauma patient
> > > >Date: Sat, 22 Oct 2005 11:07:43 -0400
> > > >
> > > >We NEVER use colloids in initial resuscitation, prehospital or
> >otherwise.
> > > >The literature clearly does not support colloid use.
> > > >
> > > >Steve Smith
> > > >
> > > >-----Original Message-----
> > > >From: oded private <tangentcarrot at hotmail.com>
> > > >To: trauma-list at trauma.org
> > > >Sent: Fri, 21 Oct 2005 18:25:32 +0200
> > > >Subject: Colloid infusion in the trauma patient
> > > >
> > > >
> > > >Hello trauma list
> > > >
> > > >Lately, I have been dealing with the teaching of fluid ressuscitation
> >in
> > > >trauma to EMT-B'S (not directly by teaching but by dealing with
> >contents
> > >of
> > > >the class and consulting with instructors) and the subject of the use
> >of
> > > >colloid solutions (under the doctor's order only. of course) came up,
> >so
> > > >I'd like t o here from those of you who have had expreince with this
> > > >therapy (both in the pre-hospital and trauma-room settings) to share
> >your
> > > >knowledge and experience with me- what solutions did use? does any of
> >you
> > > >continue to practice this therapy? did you find it to have
significant
> > > >adventages over using soley cristalloids? How did you avoid or manage
> >its
> > > >complications and dangers?
> > > >
> > > >Looking forward to your respondes and wishing you a happy succot,
> > > >Oded
> > > >
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